CARE COORDINATOR MA - POPULATION HEALTH
Status: Full Time
Shift: M-F 0800-1630
Exempt: No
Summary:
JOB PURPOSE:
The Care Coordinator is responsible for supporting clinical care teams by coordinating care for patient populations. The Care Coordinator is responsible for engaging the clinical care team and integrating population health across the health system.
Responsibilities:
FACTORS RELATING TO THE JOB
A.Experience, Knowledge and Skill
1.Previous Experience Required:
A minimum of 2 years of clinical experience as a medical assistant in the ambulatory setting is required; previous experience in primary care or population health management related role preferred.
2.Specialized or Technical Education Required:
High school diploma or equivalent,
Maintains Certificate as Medical Assistant
Maintain BLS certification.
3.Manual or Physical Skill Required:
Must be capable of assisting with the lifting and moving of patients. Must have knowledge of body mechanics. Must be capable of prolonged standing and walking.
4.Physical Effort Required:
Strength:MediumPush:OccasionallyPull:Occasionally
Carry:Occasionally Lift:OccasionallySit:Frequently
Stand:FrequentlyWalk:Frequently
B.Work Complexities
1.Complexity and Difficulty of Work:
Must be able to work independently, efficiently, and cheerfully in a busy environment with a high level of patient contact.Must possess the maturity necessary for establishing and maintaining a good work relationship with patients, family, physicians, and other staff members. Must be familiar with patient flow across various clinical settings. Must be able to multi-task and work in an organized manner.
2.Seriousness of Errors.
Errors in performance of patient care procedures could result in serious consequences to patient well-being and safety.Failure to report unusual physical and emotional patient problems immediately could result in serious harm to patient well-being.
C.Working Conditions
1.Hazards:
Contact with blood and body fluids. Must have a thorough knowledge of infection control procedures and Universal Precaution techniques.
2.Adverse Working Conditions:
Must be able to maintain cheerful, positive attitude while performing duties in a high volume practice.
D.Contacts
1.Contacts with Customers, the General Public or Other Companies:
Extensive contact with patients, patient family members, clinical care teams, employer groups, payer partners, and the community.
2.Contacts with Other Departments:
Significant contact with other departments.
E.Responsibilities:
1.Responsibility for the safety of others:
Responsible for following all policies and procedures to assist in maintaining a safe environment.
2.Responsibility for Company Funds or Property:
Maintain all equipment in the office in a conscientious manner thereby ensuring that all equipment is in proper working order.
3.Responsibility for Confidential Information:
Safeguard and preserve confidentiality of medical records and patient information at all times.All conversations regarding patients or patient’s information are to be conducted with discretion and with confidentiality in mind. Follow HIPAA privacy standards.
4.Responsibility for Performance of Work without immediate supervisor:
Must be highly motivated self-starter able to perform well without direct supervision.Must be able to function productively.The management team will be available to give advice or instructions as needed.Work is subject to review at any time.
5.Responsibility for the Supervision of Others:
None
DESCRIPTION OF DUTIES:
1.Conduct timely outreach to assess current health status, implement interventions and make referrals to meet patient’s condition specific needs.
2.Implements appropriate evidenced-based guidelines, monitors care plan compliance and reduce barriers to success.
3.Assist with coordinating services as needed (i.e. appointments, laboratory testing, radiological testing, durable medical equipment, home health, etc.).
4.Utilizes data and tools to risk stratify patient population to identify patients at risk for poor health outcomes and maintain adequate/accurate documentation for metric tracking.
5.Ensure patients with complex needs who are likely to benefit from it receive proactive, relationship-based care management (i.e. longitudinal care planning, chronic care management, behavioral health care planning, etc.).
6.Collaborates and advocates for patients with clinical care team, patient, family and/or caregivers to identify health goals.
7.Facilitate patient engagement with care team and assist with access to and navigation across health system.
8.Appropriately documents interventions in patient electronic medical record.
9.Participates in team meetings, performance improvement and patient satisfaction initiatives.
10.Provides information to the clinical care team on gaps in care.
11.Pend orders to providers per evidence-based guidelines to close gaps in care.
12.Update, maintain, and verify data and registry reports.
13.Represent population health management team on various committees and councils, as assigned.
14.Assist in coordinating quarterly Patient and Family Advisory Council.
15.Serve as a liaison between payer partners, population health management team, and clinical care team to achieve comprehensive care coordination and optimize program performance.
16.Communicate effectively by expressing ideas clearly, actively listening and always following appropriate channel of communication.Demonstrate responsiveness to others ensuring a complete follow-up on matters requiring additional attention.
17.Follow any other job related instructions and perform any other job related duties as requested by department management.
18.Consistently attend monthly staff meetings.
19.Follow associated North Oaks Health System and North Oaks Physician Group compliance programs and federal and state regulatory guidelines.
20.Complete 10 hours of continuing education per year.
21.Performs other duties as assigned.
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