Primary, Dental, and Behavioral Health
|Patient Care Coordinator|
|Contact Name:||Lisa Adams|
|Date Posted:||May 10, 2021|
CMA experience working with the medical home concept preferred. Some experience working for a non-profit community health clinic preferred.
Previous experience working with EHR, preferably eCW
Patient Care Coordinator
Under the direction of the Director of Population Health, as well as oversight by the Clinic Administrator/Supervisor, the Patient Care Coordinator is part of the primary care practice team and is responsible to assist with coordinating and providing panel management services to patients within the practice who are at most risk for health deterioration or poor outcomes.
Through close collaboration with the primary care team, the Patient Care Coordinator’s role is to provide health coaching to patients to assist them in becoming informed and active participants in their care. The Care Coordinator uses a culturally-sensitive approach with all patients - in person, by telephone, or web portal. The Patient Care Coordinator also works with the Care Team to increase patient’s access to appointments, services and health care resources thereby, supporting patient’s self-care management goals.
Utilizes weekly patient lists to prioritize and execute encounters with patients who are eligible for, or already enrolled in health coaching.
Makes outreach calls to patients missing appointments based on preventative and chronic disease guidelines.
Delegates ECW telephone encounters and Web Portal messages to CMA’s, RN’s and Providers.
Tracks and reports the progress of assigned tasks, keeping a log of discussion topics for team meetings and calls.
Joins each medical visit to understand care plan, and then meets with the patient in a private space to discuss the care plan, understand the patient’s level of engagement, and provide health coaching according to protocol.
Conducts weekly-to-monthly follow-up health coaching sessions by telephone according to protocol.
Documents patient’s progress in electronic medical record and completes all other required documentation in timely manner.
Maintains good communication with providers regarding treatment plans, special needs, and progress of patients enrolled in health coaching.
Reinforces information given to the patient and/or family with handouts to improve patient self-management skills and communication.
Provides as-needed teaching to patients during medical appointments.
Acts as a point of contact for patients and families for asking questions and raising concerns through the patient web portal and via phone.
Participates as a member of the multi-disciplinary Care Team.
Completes other job duties/tasks as assigned.
Teaching & Education:
1. Promotes teamwork by working in cooperation with coworkers and supervisory staff.
2. Good interpersonal skills; ability to engage with patients effectively during both in-person and telephone encounters.
3. Communicates effectively with staff and the public.
4. Able to use critical thinking to make decisions and problem solve.
5. Accepts and uses direction and supervision.
6. Ability and willingness to self-motivate, prioritize, and be agreeable to change processes to improve effectiveness.
7. Interacts in a manner which is professional, respectful, positive, helpful, and promotes trust.
8. Adapts to changing patient or organizational priorities.
9. Demonstrated ability to work and communicate with people from various ethnic, socio-economic, educational and experiential backgrounds.
10. Adheres to Infection Control protocols.
11. Acts in a manner consistent with HIPPA, the Corporate Compliance Program and Code of Conduct.
1. Display knowledge of normal signs of human development and ability to assess and provide age appropriate care.
High School Diploma or GED required
CMA certification required
Long Term Disability