Care Coordinator

Position Title: Care Coordinator

Reports to: Site Practice Manager

Purpose of Position:

The Care Coordinator works as part of the clinical team and is responsible to provide nursing care and related assistance to patients/families. The Care Coordinator is involved in both direct and indirect patient care, and is engaged to make contact with patients that are difficult to reach. The Care Coordinator addresses chronic medical needs and facilitates assistance within their scope of practice. Care Coordinator will act as a member of the care team and work in collaboration with other health team members and is responsible for assisting in the promotion of the health and well-being of a panel of patients. The Care Coordinator will do clinical care management which includes pre-planning and follow-up care, for the patients. They will provide follow-up care for patients that are returning from in-patient care and check with patients regarding any missed appointments.

Contribution to the Carevide Mission:

Carevide is a non-profit healthcare provider that provides services to thousands of underserved and uninsured individuals across the Northeast Texas area. Each team member’s role is vital to the success of Carevide’s mission. Care coordination has a meaningful impact on the mission as follows:

Accessible Healthcare: Carevide’s foundation is built on providing access for underserved individuals who have challenges accessing healthcare services in their communities. Clinical support teams play an essential role in facilitating access to healthcare services at Carevide through direct patient care, care coordination, and assuring linkages to additional services such as behavioral health, dental care, pharmacy services, and social services. Clinical support teams are in a unique position to ensure patients are cared for with compassion, dignity, and a high level of customer service during their care at Carevide.

High-Quality Healthcare: As a federally qualified health center, Carevide is held to high-quality patient care and safety standards. Care coordination is key to delivering quality healthcare and improving patient outcomes. Clinical care coordination teams contribute to quality patient outcomes by supporting clinicians in patient care while assuring quality care is provided, gaps in care are addressed and quality metrics are achieved organizational-wide.

Financial Sustainability: Carevide is committed to a value-based model of healthcare delivery where a priority is placed on improving patient outcomes, provider performance, and positive patient experiences. Carevide participates in pay-for-performance contracts with insurance payers that incentivize performance on quality metrics and reward high-performing health centers through financial incentives. Care coordination is a vital component of closing healthcare gaps, improving patient health outcomes, and earning incentive revenue for the health center’s ongoing operations.

Characteristics/Skills:

• Interpersonal skills:
  • Ability to work with patients from diverse socio-economic backgrounds.
  • Acts as a member of the care team, working in collaboration with the clinical and non-clinical staff to promote the health and wellbeing of the patients.
  • Strong communication skills to relate to patients/families, and other health care team members.
  • Treating all patients with dignity and compassion without creating barriers.
  • Maintain professional atmosphere in the clinic, and promote Carevide in a positive manner in the community.
• Organizational skills:
  • Ability to manage multiple priorities and remain highly efficient.
  • Closing the loop on treatments plans, diagnostic imaging, referrals and lab test.
• Clinical skills:
  • Excellent clinical skills
  • Maintain standards of care and patient safety
  • Interpreting reports, data and medical information
  • Ability to educate on disease process and outcomes
  • Ability to document clearly with accurate medical terminology

Essential Functions:

Functions and job duties may vary from site to site but may include all or many of the duties below. Care coordinator may temporarily perform other duties as assigned to maintain operations and services.

• Closing the loop on treatment plans, diagnostic imaging, referrals and lab test.
• Assist with chart audits, tracking logs, vaccine logs and inventory, abnormal pap logs, and referrals as directed.
• Manage cycle time and alert provider and care team of inefficiencies
• Assists care team in times of increased cycle time.
• Return patient calls that are tasked from the PSC.
• Cover MA’s when they are out or as needed
• Room/intake all care coordination patients as feasible
• Pre-visit chart audits for care coordination patients
• Maintain protocols/ health guidelines in patients EHR chart
• Obtain records for hospital follow-ups
• Medication refill back-up for care team
• Prior authorization for medications
• DME, home health paper work coordination
• Surgery clearance coordination
• Help care team with diagnostic imaging test actions
• Laboratory coverage as needed
• Huddle management for care coordination
• Special provider projects
• Employee will participate in ongoing training activities as provided by the organization related to assigned tasks and providing patient-centered care.

Evaluation:

Evaluations of work performance will be on-going, and will be carried out by the Practice manager, and will include specific duties and responsibilities of this position description along with employee professionalism and general working behavior. Formal evaluations will normally be performed annually, but may be initiated at other times be the clinic manager.

General Qualifications and requirements:

• Completed an accredited RN or LVN program, and is currently licensed by the Texas Board of Nurse Examiners or have completed an accredited Medical Assistant program.
• 1 year of experience in Family Medicine. Experience with administrative duties and knowledge of Microsoft Office are required.
• Basic Life Support certification