Job Description

• Experience in coordination care for individuals with chronic conditions and complex medical and social needs.
• Experience participating in hospital care transition improvement programs.
• Ability to adapt to evolving goals and requirements and to test new approaches to improved patient care.
• Displays evidence of excellent leadership skills along with verbal, written, and interpersonal skills.  
• Displays critical thinking and clinical problem-solving skills.
• Computer skills with proficiency in Electronic Health Record, Microsoft Products (Word, Excel, Outlook,  

• Five years of experience in the healthcare field, navigating the exchange, and/or financial counseling experience, preferred.

• Preparation of statistical data, financial statements, and reports to granting entity.
• Preparation of correspondence, various reports, policy manual, and other administrative reports relating  to the clinic.
• Care coordination for physician patients, interviewing and directing visiting personnel and patients to appropriate offices.  
• Answers telephone makes appointments and perform related receptionist duties.
• Maintains records of appointments and meetings for the physicians as needed.
• Ensures a high level of customer service in the clinic and resolves issues promptly that may arise.
• Provide suggestions for service improvement.
• Enters patient data into designated registry/documentation system and generate reports as needed.
• Coordinates scheduling of patient visits and referrals.
• Actively supports and participates in community events that the physicians are supporting.
• Provide follow-up when transitions occur, possibly including performing telephonic follow up or home visits for applicable patients and ensure a smooth transition from hospital/community facility to home.
• Assures the consistent implementation of the treatment plan with the CCT through ongoing coordination and communication with various health care team members.  
• Collaboratively functions across the continuum of care.
• Utilizing health behavior change techniques, identify patient readiness for self-management and barriers to optimal care, and implement interventions that address patient needs with the goal of improving or maintaining the health status of the patient. Document care into electronic health record or registry.
• Participate in hospital committees and initiatives as they relate to improving operations, patient education, gap closure and reducing preventable hospital readmissions.
• Actively participate and support initiatives in any Payer Pay for Performance or Quality Improvement Plan as designated by the CCT Director.

• Effectively communicates with the physicians to ensure an effective continuum of care: 
• Daily communication with the physicians
• Provides financial interventions/recommendations to the CCT and physicians
• Assists the physicians to recognize and resolve care gaps
• Scribes for physicians as needed to optimized patient flow
• Quality Assurance Oversight
• Responsible for acquiring knowledge of accountable care act requirements to maintain compliance and improve value-based proposals and pay for performance measures, ensures accountability of assigned insurers outcomes and improvements
• Works with Marketing on MD education programs and community education and marketing
• All other duties as required or assigned

• Ability to work as a part of an interdisciplinary team with primary care physicians and other clinicians in a professional manner.
• Understanding of health care disparity issues, financial interventions, and the ability to interact with patients and families of diverse cultural backgrounds.
• Ability to adapt to evolving goals and requirements and to test new approaches to improved patient care.
• Displays evidence of excellent leadership skills along with verbal, written, and interpersonal skills.  
• Displays critical thinking and clinical problem-solving skills.
• Ability to use independent judgment and compassion when carrying out tasks.
• Commitment to improving patient outcomes and community engagement.