Job Description

Explore opportunities with Holston Medical Group, part of the Optum family of businesses. Holston Medical Group combines the personal feel of a community-based practice with the strength, resources and career opportunities of a leading national health care organization. As a multispecialty clinic offering care across northeast Tennessee and southwest Virginia, our teams deliver high‑quality, value‑based care that exceeds expectations while making care easier, more affordable and more accessible. Join us and discover the meaning behind Caring. Connecting. Growing together.

Pay Range: $20.10 - $28.95

General Summary: The Clinical Care Coordinator will outreach to any patient with a recent hospital admission/discharge, addressing the patient needs and working with the patient to minimize risk of readmission. They will work with the patient for education of a chronic disease state such as, but not limited to, hypertension, diabetes, COPD, CHF, and renal disease. The Clinical Care Coordinator will also work to address patient needs when the Primary Care provider sends a Care Coordination referral on a patient. They will act as a go between for the patient and primary care provider or specialty provider that is assigned to this patient’s care team and will schedule patient appointments as needed. The Clinical Care Coordinator will track the patient engagement/enrollment in Care Coordination on tracking spreadsheet (s).

Main Responsibilities:

• Establish close relationships with patients that will increase compliance with treatment recommendations and patient management plans
• Maintain communication with providers and collaborate care with patient
• Maintain strict confidentiality in all matters relating to patient PHI (Patient Health Information)
• Review data within the patient chart which can be used to attest for a HEDIS measure and outreach to the patient for review/discussion of the specific gaps in care
• Coordinate and schedule appointment for patients to address specific gaps in care. Review payer scorecard and work with Operations Management Team to improve overall STAR rating for the group
• Coordinate and schedule appointments for patients to address specific patient need
• Ensure appropriate documentation or results are listed within the EHR, complete manual attestations within the payer’s system for HEDIS gaps in care reporting
• Review payor scorecard for patient gaps in care.
• Work with Manager or Clinical Care Coordinator Team Lead on payer scorecards and ways to potentially increase overall STAR rating for organization
• Pull the eligible patient list, perform chart review to determine if a patient may qualify for the Eastman Hypertension or Diabetes Program based on program criteria, and work with the Program Director for potential enrollment in the program.
• Keep track of the patients enrolled in the program utilizing a patient list
• Responsible for generating and sending monthly and biannual invoices to Eastman for the patients who are enrolled in the program.
• Responsible for scheduling patient follow up visits and helping to educate the patient on the disease states of hypertension and diabetes.
• Work with resources onsite at Eastman for continuation of patient education/disease management and will make appropriate referrals to Cigna Case Management as needed; and will provide Manager or Clinical Care Coordinator Team Lead a weekly list of patients who are outreached for reporting to Cigna Eastman insurance.

Education/Experience/Knowledge:

• Minimum high school diploma or equivalent required
• LPN licensed by the state in which employed or Registered/Certified Medical Assistant
• Ability to work independently with strict adherence to protocols in an accountable manner
• Empathetic and patience to patient/patient family
• Excellent communication skills – both written and oral
• Superb time management, organizational, critical thinking, and problem-solving skills

Key Competencies:

• Compassion
• Customer focus
• Ethics and values
• Interpersonal savvy
• Problem solving
• Critical thinking skills
• Empathy
• EHR and scheduling proficiency
• Basic knowledge of Microsoft Office
• Knowledge of HEDIS Gap Measures

Physical/Mental Demands:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Essential:

Communication with others to exchange or express information and ideas. Ability to receive detailed information through oral communication, and to make fine distinctions in sounds. Determine the accuracy, neatness, and thoroughness of the work assigned and perceive general observations. Must be able to remain in a stationary position at least 75% of the time. Extending the hands and arms in any direction. Constantly operations a computer and other office productivity machinery, such as a calculator, copy machine, and computer printer. Perform a variety of duties, often changing from one task to another of a different nature. Perform with frequent interruptions and/or distractions. Make appropriate job decisions following standard office policies and past precedents. Adjust priorities quickly as circumstances dictate. Ability to establish and maintain cooperative working relationships with co-workers and the public. Work independently and identify potentially more effective methods of work operations. Ability to interact appropriately with colleagues and patients for different purposes and different context.

Marginal:

Needs to move inside or outside the office space to access file cabinets. Sedentary work that includes moving objects up to 10 pounds. Observing an area that can be seen up and down or to right or left whiles eyes are fixed on given point. Ability to identify and distinguish colors. Light work that includes moving objects up to 20 pounds occasionally.

Disclaimer:

The above statements are intended to describe the general nature and level or work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. Management reserves the right to revise the job or to require that other of different tasks be performed as assigned.

All job requirements are subject to possible revision to reflect changes in the position requirements or to reasonably accommodate individuals with disabilities.