Chronic Care Coordinator

Primary Purpose

The person in this position is a member of the Patient Centered Medical Home (PCMH) team where each team member plays an integral role in providing patient-centered health care. The incumbent is responsible in developing individualized person-centered care plans for patients with complex and chronic illness in accordance to KPHC's clinical care coordination model and evidence-based practice guidelines. S/he participates in healthcare innovation, leads projects, and activities that promotes quality patient care and improve health outcomes.

Essential Duties

• Leads the PCMH practice team in team-based communication, planning, developing, and implementing care coordination activities to improve patient outcomes.
• Assess the needs of patients and facilitates referrals and care coordination with internal and external stakeholders as appropriate.
• Provides patient education, sets SMART goals.
• Establishes person-centered care plan in collaboration with the patient and provider following NCQA-PCMH guidelines.
• Identifies gaps in the care of the patient and ensure that gaps are closed in alignment with NCQA-PCMH, HEDIS, and health plan requirements.
• Executes effective interventions to reduce inappropriate ER visits or length of hospital to improve care and reduce costs.
• Provides staff training as it relates to care coordination and chronic diseases as appropriate.
• Organizes and coordinates chronic disease patient classes such as diabetes, asthma, CKD, memory clinic, etc.
• Works in concert with other internal and external teams to achieve the goals and objectives of the Patient Centered Medical Home
• Implements policies, procedures, and processes developed by the PCMH team.
• Ensures that KPHC's PCMH team asserts changes based on the components of the chronic care model, KPHC and PCMH standards and guidelines for improvements.
• Provides oversight to support staff assigned to assist in care coordination activities.
• Prepares monthly report and updates to the Director of Clinical Operations as appropriate.
• Assist the Director of Clinical Operations in quality improvement and data validation activities as appropriate.
• Serves as a liaison for care coordination to insurance companies and other organizations as appropriate.
• Explores community resources and establishes partnerships to facilitate improvement.
• Supports other multi-cultural projects to enhance the delivery of patient care.
• Performs direct nursing care such as triage, nurse advice and floor duties and/or covers other departments as necessary.
  
  

Administrative Responsibilities

• Supports and supervises support staff working with him or her.
• Maintains an awareness of services offered through the clinic and in the community to serve client needs.
• Maintains awareness of legal and legislative issues that may impact service availability.
• Participates in clinic quality improvements activities.
• Works in concert with the adult medicine care team to assess and modify quality improvement strategies.
• Maintains client confidentiality per clinic protocol.
• Develops and implements forms for data collection, tracking and documentation of activities and works with the adult medicine team to determine effective communication strategies.
• Works closely with other clinic staff engaged in activities or projects involving clients as it relates to chronic disease.
  
  

Other Duties

Performs other related duties as assigned

Observes safety and security procedures; determine appropriate actions beyond guidelines; report potentially unsafe conditions; use equipment and materials properly.

Skills/Knowledge

Minimum Qualification Requirements:

Knowledge and skill in the delivery of community healthcare.

Knowledge of community resources, how to access such, and an awareness of government assistance programs.

Ability to assess and plan in a multi-cultural context.