Job Description

The PCMH Care Coordinator I work in collaboration with the patient, family, physician/nurse practitioner and office staff within the team structure to ensure that patient-centered, cost effective, high quality care is provided. Patients under the care of the Coordinator will be supported by the development of a multi-disciplinary care plan, self-management goals and referrals to both internal and external resources.

Essential Functions, Duties, and Responsibilities

• Identify patients within the team with anticipated high cost care, recent hospital admission requiring transition of care from hospital to home, high utilization of services, complex medical needs or those at high risk for complications or exacerbation from disease.
• Link patients with community resources to facilitate referrals and respond to social service needs.
• Utilize referral protocols and agreements with subspecialists to meet patients’ needs and achieve goals and objectives in their plan of care.
• Track and support patients when they obtain services outside the center such as the Emergency Department, hospitals and other subspecialists.
• Follow up with patients within a few days of an emergency room visit or hospital discharge.
• In collaboration with providers, communicate test results and care plans with patients and families.
• Track completion of laboratory tests, diagnostic studies and referrals as directed by providers and in collaboration with clinical team.
• Provide relevant self-management support for patients with chronic illnesses as identified by clinical team.
• Work with patients both in person and over the phone to remind and review their plan of care and progress towards their goals.
• In collaboration with administrative staff and enabling services, assist patients with the process of determining eligibility and to obtain and maintain free pharmaceuticals through the Patient Assistance Program.
• Be the system navigator and point of contact for patients and families, with patients and families having direct access for asking questions and raising concerns.
• Address patient and family concerns and initiate corrective action. Bring identified issues to the attention of supervisor.
• Assist patients in problem solving potential issues related to the health care system, financial or social barriers (e.g., request interpreters as appropriate, transportation services or prescription assistance).
• Handle phone calls from patients seeking medical information and/or medical attention.
• Schedule appointments as the patient’s condition require, answer questions, and provide limited health education.
• Assist the office staff to appropriately identify the patient’s acute needs and direct that patient to receive the care required. Assist in transfer to hospital if needed.
• Process medication refill requests.
• Collect data and prepare reports and registries for review by the QA/PI Committee.
• Ensure timely documentation in Electronic Health Records.
• Participate in Performance Improvement/Continuous Quality Improvement activities.
• Adhere to policies/safety practices established by the Zufall Health Center.
• Maintain confidentiality of all patient information.
• Work effectively with other members of the health care team to optimize interventions.
• Works with the CMA’s and the other PCC to organize the clinical stock, check it in as it arrives, place it in the correct area whether in the clinical stock room, cabinets in the room or refrigerators. Work with the CMA’s to make sure stock is ordered in a timely manner to prevent lack of timely care for the patients.
• Maintain/rotate the Vaccine for Children stock to prevent vaccines from expiring or running out. Order vaccines in a timely manner. Assist with maintaining the registry.
• Perform other duties as assigned.

Requirements

• Knowledge of the basic concepts and principles of managed care required.
• Excellent customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
• Excellent verbal and written communication skills.
• Ability to anticipate primary care providers’ needs.
• Bilingual in Spanish/English.
• Excellent computer skills, experience with electronic medical records a plus
• Ability to interact with patients, staff and outside agencies appropriately.
• Ability to follow instructions, given either orally or in writing.
• Ability to work independently or with little supervision.
• Excellent organizational skills such as problem solving, decision making, priority setting, and work delegation.
• Ability to complete assignments in a timely manner.
• Ability to work as a team member.
• Ability to maintain HIPAA compliance, corporate compliance and client confidentiality.

Education, Training, and Experience

• Documented training in health care related field
• Licenses and Certifications as per training and education. CMAs hired into the role of PCMH I must maintain CMA, EKG and Phlebotomy certifications.
• Five or more years’ experience in a clinical setting requiring frequent contact with providers, patients and family members.
• Prior experience in an ambulatory care or outpatient clinic setting and case management experience preferred.
• Current BLS certification