Job Description

Job Title:                     

Care Coordinator 

Reports To:                 

Care Coordinator Manager

Job Purpose:                     

Collaborates with clinical team members, patients, and families to facilitate unmet health care needs within the context of the Patient Centered Medical Home (PCMH) model.

Job Classification:            

Full-time/ Non Exempt

Job Summary:

To perform this job successfully, and individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.

Essential Job Functions 

Under the supervision of the Director of Nursing, provides care coordination for patients with both acute and chronic health needs using the Patient Centered Medical Home model.

Promotes the patient Centered Medical Home (PCMH).

  • Acts as a primary resource and spokesperson in promoting, implementing and advancing the PCMH at CCHCI.
  • Regularly participates in leadership meetings.
  • Represents CCHCI’s implementation of PCMH within the context of institutional and community forums.
  • Is an active participant in quality assurance activities.

    Promotes Preventative Care

    • Coordinates preventative health care measures and health care maintenance for defined patient populations.
    • Manages insurance company correspondences regarding patient care.
    • In collaboration with provider, identifies and tracks patients in need of follow up and other testing for chronic disease management.
    • Provides logistical leadership for in-house specialty clinics.
    • Follows up on missed appointments for defined patient populations.
    • If within scope, provides patient education for disease management.
    • Organizes and facilitates care planning for defined patients.
    • If within scope, assists providers with lab and diagnostic study follow up.

    Provides Intensive Care Coordination

    • Serves as a direct resource to patients and providers on a daily basis.
    • Facilitates hospital admissions.
    • Arranges for medical care in the home.
    • Home health and hospice referrals.
    • Durable Medical equipment (DME) and in home oxygen needs.
    • Tracking of hospitalized patients.
    • Coordinates follow up upon discharge and the obtaining of in-patient medical records.

    Coordinates Specialty Care

    • Builds and maintains relationships with specialists and other medical services.
    • Negotiates rates for underinsured and uninsured populations.
    • Follows up on outstanding referrals.
    • Assists patient with potential barriers to specialty care.
    • Collaborates with leadership to coordinate in-house clinics for visiting specialists.
    • Provides assistance with transportation.
    • Manages and submits necessary documentation to insurance for coverage of transportation.
    • Negotiates rates with local transportation companies for uninsured populations.

    Utilizes Community Resources

    • Maintains a comprehensive, current database of community resources.
    • Facilitates communication with community organizations as a patient advocate.
    • Organizes support groups.
    • Manages funds set aside to assist patients according to established guidelines.
    • Facilitates completion of paperwork and applications.

    Education and/or Experience

    • Minimum of a bachelor’s degree preparation in a field of case management, social work or the equivalent and/or 3 years of appropriate past experience in the health care field, OR Licensed Nurse.

    Language Skills

    • Ability to read, comprehend and write instructions, correspondence and memos. Fluency in both English and Spanish preferred.
    • Ability to gather data in an organized fashion from varied sources

    Mathematical Skills

    • Ability to calculate figures and amounts
    • Proficient with MS Office, including Word, Excel, Outlook and Internet (experience with EMR preferred)

    Reasoning Ability

    • Ability to carry out instructions furnished in oral, written or visual format.
    • Ability to perform a variety of assignments requiring considerable exercise of independent judgment.

    Certificates, Licenses and Registrations

    • Must be furnished upon request to support education and experience claims.

    Other Skills and Abilities

    • Knowledge of health plans and community health centers preferred