Patient Care Coordinator

Job Title:         Patient Care Coordinator

 Supervisory Responsibilities:

 None

 Position Summary:

Employee reports directly to the Director of Quality Assurance. The Primary duty of the Patient Care coordinator is to connect patients with medical resources and support systems and to facilitate interaction and communication with healthcare staff and providers.  The Patient Care Coordinator may be required to attend Administrative meetings. The Care Coordinator serves as the bridge between the Patient Care Plan and support of patients’ lifestyle needs.   

Description of Responsibilities:

1. Educates patients on the importance of a medical home and the difference between Primary Care and care under the PCMH model.
2. Provides between-visit patient outreach to assigned/referred patients with 2 or more chronic illnesses who show a consistent pattern of out-of-range values for our inclusionary criteria/targeted measures.                 
3. Assists service departments (nursing staff, Nurse Manager/Director, Provider) toward improving patient visit consistency, partnership, and health outcomes.
4. Supports medical home processes (i.e., treatment team and huddle meetings, as needed).
5. May be required to oversee and evaluate the performance of other staff.
6. Links assigned patients with appropriate resources and referrals.
7. Supports insurance payors, as assigned, with measure improvement efforts - external portal measure validation and re-scheduling to close SMC patient care gaps.
8. Maintains personal knowledge base of available resources, both in-house and within local communities.
9. Assists with the preparation of administrative reports.
10. Provide updates of patient progress to be placed in the EHR.
11. Provide system-based educational material, prevention handouts and assist with distribution of literature for chronic disease states such as Hypertension, Diabetes, Obesity, Depression, Pediatric Asthma (Asthma Action plans), and HIV linkage to Care.
12. Assist patients in completing computer-based surveys regarding level of understanding of their chronic disease state.
13. Support measure improvement activities through our Accountable Care Organization (ACO, Medicare effort) and Independent Practice Association (IPA, Medicaid effort). 
14. Support patient forum events.
15. Other related duties as assigned.

 Knowledge, Skills & Responsibilities:

      1.Excellent oral and written communication skills.

      2. Ability to maintain confidentiality of information to include protected health    

             Information.

1. Ability to work as a member of a team and promote teamwork with other staff 

            members.

1. Ability to work with patients in a compassionate, non-judgmental manner.
2. Ability to work and act independently.
3. Effective knowledge and use of computers and multiple programs for daily work and projects.
4. Understanding of the potential business impact of social media.
5. Ability to manage multiple projects.

Minimum Qualifications:

 Must have a High School Diploma and at least two (2) years of experience working in community outreach, community resource development or casework participation.  Basic knowledge of computer applications is essential. Carries out independent fieldwork, maintains records, and participates in cooperative efforts with numerous agencies and programs.  Bilingual a plus. Certified Medical Assistants (CMA) are preferred.

 Typical Physical Demands:

 Requires some standing/walking/sitting.  Requires travel from one site to another.  Use of telephone required.

Typical Working Conditions:

 Eight (8) hour workday.   Some contact with patients and staff