- Has a schedule that shows designated hours for Care Coordinator to complete the functions of care coordination.
- Enrolls patient in HCH and coordinates patient care.
- Use effective engagement strategies to build a trusting relationship with patients and families for ongoing partnership in their health care decisions.
- Use a variety of educational materials, self-management support techniques, and community resources to engage patients, increase their motivation to change, and support patients and families in establishing healthy lifestyle goals and implementing treatment plans to meet those goals.
- Develop a maintenance plan with patients to help them maintain a healthy lifestyle.
- Contacts patients frequently (according to protocol) and arranges appointments with primary care provider (PCP) and specialists as needed.
- Coordinates and facilitates communication between patient, families, primary care provider (PCP) and consulting specialists.
- Supports patient with treatment compliance.
- Assists patient when barriers to care arise.
- Collaborates with PCP on outcome assessment using care plans.
- Reviews caseload with PCP, focusing on patients not adequately improved within specified timeframe.
- Assists patient in scheduling appointment with other health care providers and coordinates with the referral coordinator.
- Documents all encounters in ECW according to Entira Family Clinics policies and procedures.
- Helps maintains registries as directed.
- Works with resources provided for care coordination and helps develop additional resources as needed.
- RN, LPN CMA, MA, psychology, social work, health education or clinical background with a minimum of an associate degree or equivalent experience.
- Ability to manage a project from start to finish.
- Ability to learn quality improvement principles/tools and methods.
- Demonstrated ability to effectively establish and maintain collaborative working relationships with peers and constituents at all levels of an organization.
- Knowledge of medical terminology.
- Good desktop tool usage including Word, Excel, PowerPoint, and EMR.
- Excellent communication skills, both verbal and written.
- Demonstrated analysis and problem solving skills.
- Healthcare Flexible Spending Account (FSA)
- Health Savings Account (HSA)
- Group Life
- Voluntary Life
- Voluntary Disability
- Profit Sharing
- Employee Assistance Program
Job Type: Full-time