Care Coordinator

Job Description

OPSAM HEALTH MISSION

We exist to provide quality and patient-centered healthcare to every member of the communities we serve, regardless of the ability to pay.

OPSAM Health is a Federally Qualified Health Center (FQHC) that serves the San Diego County community. Founded in 1973 in a barber shop in Downtown San Diego by Filipino health professionals offering services to immigrants who did not have the finances, linguistic skills, or ability to navigate the health care system. Today, Operation Samahan has evolved into a diverse community health center with services available in National City, Mira Mesa, City Heights, and Rancho Penasquitos. We provide primary care, dental, behavioral health, family planning, integrative health and wellness, healthy eating, civic engagement, and other health related services to the uninsured, underinsured, and underserved families of all income levels regardless of their ability to pay.

 JOB PURPOSE  

This position is responsible for Orienting and educating patients and their families by meeting them; explaining the role of the patient care coordinator; initiating the care plan; providing educational information in conjunction with direct care providers related to treatments, procedures, medications, and continuing care requirements

 ESSENTIAL DUTIES AND RESPONSIBILITIES  

• Orients and educates patients and their families by meeting them; explaining the role of the
• patient care coordinator; initiating the care plan; providing educational information in conjunction with direct care providers related to treatments, procedures, medications, and continuing care requirements.
• Provide Medical Assistant coverage to the Podiatry Services and float when needed.
• Provide transportation services on an as needed basis only after all other resources have been exhausted.
• Assists patients with their mobility concerns as needed.
• Assists all patients through the healthcare system by acting as a patient advocate
• Leads and participates in daily care team huddle to assist in pre-visit planning and identifying patients who may benefit from an integrated visit with care management/coordination services.

• Coordinates continuity of patient care with patients and families following hospital admission, discharge, and ER visits.
• Manages Population Health and Disease Care Gaps in conjunction with Hedis team
• Facilitates health and disease patient education,
• Supports patient self-management of disease and behavior modification interventions.
• Monitors high utilizers of services.
• Addresses Preventative health—including school located flu clinics.
• Manages high risk patient care, including management of patients with multiple
• co-morbidities or high risk for readmission to a hospital setting.
• Assists population health with data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Patient Centered Medical Home initiatives as appropriate.
• Performs job utilizing the policy, protocols and standing orders for delivering care coordination.
• Documents patient records using an Electronic Health Record.
• Participates in Patient Centered Medical Home team meetings and quality improvement initiatives.
• Assists both Quality & Compliance in improving the policy/procedures for the Clinical staff including Mas and Providers

NON-ESSENTIAL DUTIES AND RESPONSIBILITIES

COMPETENCIES

• Good organizational skills to handle multiple priorities while remaining
• professional and calm.
• Ability to work with many diverse people.
• Effective telephone skills.
• Strong level of confidentiality due to the sensitivity of materials and information handled.
• Must be able to make suggestions on workflow or system efficiency and effectiveness.
• Ability to work independently and be self-directed and flexible.
• Ability to prioritize.
• Ability to perform functions with minimal supervision.
• Ability to work at a high-volume level of accuracy.

GENERAL EXPECTATIONS

• Be committed to the mission of the Opsam Health.
• Behave in a professional manner and consistently demonstrate and promote the values of       respect, honesty, and dignity for the patient, families, and all members of the healthcare team.
• Committed to the constant pursuit of excellence and teamwork in improving the care of the patient and families of Opsam Health through a Patient Centered Medical Home model (PCMH) .
• Be punctual for scheduled work and use time appropriately.
• Perform duties in a conscientious, cooperative manner.
• Perform required amount of work in a timely fashion with a minimum of errors.
• Be neat and maintain a professional appearance.
• Maintain confidentiality and protect the Opsam Health by abiding by laws and principles related to confidentiality; keep information concerning Practice Operations, patients, and employees confidential.
• This position requires compliance with OPSAM’s compliance standards, including its Standards of Conduct, Compliance Program, and policies and procedures. Such compliance will be considered as part of the Care Coordinator’s regular performance evaluation.

EXPERIENCE AND SKILLS REQUIRED

• Medical Assistant Program completion REQUIRED
• The following experience and skills are considered essential:
• Minimum of 3 year of professional level medical assistant experience; experience in care
• coordination preferred.
• Experience working with an electronic medical record required.
• Ability to work collaboratively with people of diverse cultures and lifestyles.
• Ability to communicate effectively with providers and medical staff.
• Excellent organizational skills and ability to handle multiple priorities while remaining calm and professional.
• Ability to be self-motivating and work independently.
• Computer literacy.
• Excellent written and oral communication skills.
• Problem solving skills.