Job Title: Care Coordinator
Reports To: Care Coordination Supervisor
Job Summary: 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.
Essential Job Duties and Responsibilities:
The job duties and responsibilities listed below are representative of the knowledge, skill, and/or ability required. Other duties that fall within the broad scope of this classification may be assigned.
- Promotes the PCMH Model
- Assists in promoting and implementing PCMH initiatives.
- Regularly participates in leadership, staff, and other quality improvement meetings to educate staff and facilitate participation in PCMH initiatives.
- Represents CCHCI’s implementation of PCMH within the context of institutional and community forums.
- Performs duties related to Quality Department projects as assigned.
- Promotes and Provides Care Coordination
- Coordinates preventative health care measures and health care maintenance for defined patient populations.
- Manages insurance company correspondence regarding patient care.
- Identifies and tracks patients in need of follow up and other testing for chronic disease management in collaboration with provider.
- Follows up on missed appointments for defined patient populations.
- If within scope, provides patient education for disease management and assists providers with lab and diagnostic study follow up.
- Organizes and facilitates care planning for defined patients.
- Arranges in-home medical care such as home health, hospice, and in-home durable medical equipment and oxygen needs.
- Facilitates hospital admissions.
- Tracks and coordinates follow up of hospitalized patients upon discharge and obtains 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.
- Coordinate in-house clinics for visiting specialists in collaboration with leadership team.
- Manages and submits necessary documentation to insurance for coverage of transportation.
- Negotiates rates with local transportation companies for uninsured populations.
Minimum Qualifications - Experience, Certificates & Licenses:
- High School Diploma or GED
- At least two years of experience in case management, nursing, or other related health care field.
- Any combination of education and/or experience that provides the necessary skills required may be considered.
- CPR certification may be required for licensed staff.
- Valid Fingerprint Clearance Card may be required.
Preferred Qualifications - Experience, Certificates & Licenses:
- Associate degree in a field of case management, social work, or related field preferred.
Required Language Skills:
- Ability to comprehend and compose instructions, correspondence and communications in English and Spanish in both oral and written format.
- Bilingual in English and Spanish with knowledge of medical terminology is required.
- Ability to frequently exert enough force to move objects weighing up to 25 pounds.
- Ability to continuously remain in a stationary position.
- Ability to frequently move about inside the workplace to assist patients, operate office or medical equipment, etc.
- Possesses hand-eye coordination and manual dexterity necessary to constantly operate computer, telephone, and other office machinery.
- Possesses close visual acuity necessary to accurately record and view information on a computer monitor, handwritten and typed documents.
- Ability to discern the nature of sounds at a normal spoken volume.
Other Required Knowledge, Skills, and Abilities:
- Ability to add, subtract, multiply and divide in all measure, using whole numbers, common fractions, and decimals.
- Ability to gather data in an organized fashion from varied sources.
- Ability to perform a variety of assignments with little or no direct supervision.
- Ability to identify and resolve problems in a timely manner.
- Knowledge of health plans and community health centers preferred.
- Knowledge of HIPAA rules and regulations.
- Computer literacy required with proficiency in use of all Microsoft Office programs.
- Ability to provide excellent customer service by mail, telephone, and in-person.
Work Environment & Conditions:
- Work environment is typical of a health clinic setting with occasional exposure to communicable diseases, bodily fluids, and hazardous chemicals.
- Occasionally, work requires extended hours to include early mornings, evenings, and weekends.
Job Status: Full Time