Position Summary

The ACO REACH Care Coordinator provides patient guidance and support, focused on social determinants of health and addressing barriers to care, and serves as an advocate for PrimeCare’s Medicare patients. Through work involving health risk assessments and emergency room follow-up, the Care Coordinator’s work is a bridge to the primary care setting for PrimeCare’s at-risk Medicare patients.

Duties and Responsibilities

1. Conduct telephonic health risk assessments of Medicare patients and connect them to the appropriate community resources (insurance services, transportation, childcare, employment, legal, etc.) as well as to follow up medical visits in the medical home. 
2. Follow-up with patients who have recently visited the emergency department (ED) for an acute issue, provide education on ED use and PrimeCare clinical advice options, and schedule follow up appointments to ensure consistent follow-up at the medical home with medical and behavioral health providers.
3. Assist with identifying potential low-risk patients with frequent utilization to engage with care management services. 
4. Educate patients on the importance of preventive measures and following up with their primary care provider on a regular basis.
5. Document calls and any outreach attempts in PrimeCare’s electronic medical record (EMR) and in a secondary website for the funding entity. 
6. Serve as an integral member of the care team: review daily schedules and patient charts. Identify gaps in care and areas of need, schedule appointments, communicate needs and care plan with care team. 
7. Facilitate communication among patients, providers, nurses, medical assistants and outside resources, related to the care of patients.
8. Maintain timely and consistent communication and follow up with patients regarding their health care and resource needs. 
9. Perform population-based outreach to close gaps in care and ensure timely patient follow-up including, but not limited to, vaccine schedules, cervical cancer screening, Medicare Annual Wellness Visits, chronic condition follow-up, and prenatal care. 
10. Participate in specialized programs such as quality initiatives and workgroups, grant-funded programming, education programs, IBCCP coordination, etc.
11. Represent PrimeCare at community events, educating the community on our services and promoting our organization and programs.
12. Ability to move between clinic sites if needed to meet with patients face-to-face.
13. Other duties and responsibilities, as assigned.

Experience

1. Bachelor’s Degree or relevant experience.
2. One (1) to three (3) years of experience, preferred in social services. Background in a community health setting is highly preferred.
3. Ability to use MS Office programs, including MS Word, Excel and Outlook. 
4.  Bilingual in English/Spanish is preferred.

Physical Demands

1. Must be able to remain in a stationary position 50% of the time.
2. Must be able to move around the clinic site 50% of the time.
3. Constantly operates a computer, computer printer, copy machine, and telephone.
4. Occasionally positions self to maintain exertion of physical strength to move objects of 10 pounds from one level to another.
5. Must be able to transport from one site to another. Ability to use mass transit to move between sites.
6. Must be able to cover other shifts as necessary.

Comprehensive Health Insurance Benefits through BCBS of IL: 

• Health Insurance (HMO/PPO)
• Dental Insurance (HMO/PPO)
• Vision Insurance 
• Short/Long-Term Disability Insurance 
• Group Life Insurance 

Other Benefits Include: 

• 403(b) Retirement plan with employer match 
• Pension Plan
• Voluntary Life/ AD&D 
• Flexible Spending/Dependent Care Accounts 
• Annual CME Allowance and CME PTO (Providers Only)
• Paid Time Off
• 1 Floating holiday per calendar year
• 3 Personal days per calendar year
• 7 Holidays per calendar year
• Employee Assistance Program 
• Tuition Assistance Program
• Off-the-job Accident Coverage
•  Employee Referral Program 
•  Internal Growth Opportunities 

PrimeCare Community Health is part of the National Health Service Corps, as such, you would be able to participate in their Loan Repayment Program. For more information, please visit their website at https://bhw.hrsa.gov/loans-scholarships

In accordance with Illinois Executive order 2021-20 (COVID-19 No.87) effective on August 26, 2021, in conjunction with the Federal CDC guidelines, COVID vaccinations are now a requirement for PrimeCare Community Health as well as many other Healthcare Organizations. Proof of full vaccination is required prior to the beginning date of employment. If you have a medical or religious contraindication, please inform Human Resources when the offer is extended. 

PrimeCare Health is firmly committed to creating a diverse workplace and is proud to provide equal employment opportunities to all applicants. Therefore, PrimeCare does not discriminate on the basis of creed, color, national origin, sex, gender identity, sexual orientation, age,religion, marital or parental status, alienage, disability, political affiliation or belief, military or military discharge status.