The role of the Care Coordinator is to work in collaboration with patient and his/her primary care provider in a team approach to promoting timely access to appropriate care, increasing utilization of preventative care, reducing emergency room utilization and hospital readmissions, increasing comprehension through culturally and linguistically appropriate education, creating and promoting adherence to a care plan, increasing continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals. The Care Coordinator will also work to increase patients’ ability for self-management and shared decision-making, provide medication reconciliation, and connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs.
Knowledge, Skills, and Abilities
- Knowledge of health and disease management patient education programs.
- Ability to serve as patient advocate and navigator when guiding assigned CFHC patients through the internal and external healthcare systems.
- Ability to participate in Patient-Centered Medical Home team meetings and quality improvement initiatives to help achieve clinic goals, clinical measures and customer satisfaction.
- Ability to process and track referrals and diagnostics.
- Ability to process recall list from chronic care management reports and insurance payers in a timely manner to include, but not limit to, completion of service request, completion of forms (manually or electronically), and appropriate follow-up, in an effective and appropriate manner.
- Knowledge of Health Information Technology (HIT) systems and be able to document recall status in patient’s electronic medical records.
- Ability to assist patients in problem solving potential issues related to the health care system, financial or social barriers.
- Must demonstrate emotional stability, ability to cope with stress and be non-judgmental towards patient diversity.
- Must be able to organize and use time and resources effectively.
- Must be able to follow and give oral and written instructions clearly and precisely.
- Maintain confidentiality with all aspects of information in accordance with practice, State and Federal regulations.
- Must be able to sit, stand, bend, lift and move intermittently during the workday.
- Must be proficient using Electronic Health Records (EHR) and Electronic Practice Management (EPM) systems and possess intermediate level skills on Microsoft Office Suite.
Must be a Licensed Practical Nursing (LPN) or graduate of an accredited school of medical assisting (MA) in good standing with the State of Mississippi. MA position requires registration or certification by a nationally recognized certifying body. Nationally recognized certifying bodies include the American Association of Medical Assistants (AAMA), the American Medical Technologists Agency (AMT), and National Center for Competency Testing (NCCT), and the National Health Career Association (NHA). Two years of clinical and administrative experience in a primary care practice, community health, or public health setting is preferred.
- Directs and supports patient self-management of disease and behavior modification interventions.
- Coordinates continuity of patient care with patients and families following hospital admission, discharge, and ER visits.
- Manages high-risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting, including a registry.
- Conducts comprehensive, preventive screenings for patients and/or assists all support staff in daily patient interactions as needed.
- Knowledge of patient medication management based upon standing orders and protocols.
- Schedules and tracks diagnostic and specialty referrals, including obtaining prior authorizations and insurance criteria.
- Conducts internal and 3rd party recalls.
- Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Patient-Centered Medical Home and Medical Neighborhood initiatives.
- Performs timely follow up on pending/outstanding patient appointments and document updates in the patient’s record.
- Performs other related duties as assigned or requested.
- Upholds, complies with, and enforces the Core Principles and Code of Conduct.
Please submit resumes with the position apply for on the subject line to firstname.lastname@example.org