Care Coordinator (Healthcare)
Position Overview
A successful Care Coordinator must be passionate about healthcare and want to make a difference in the lives of others while acting as a mission-driven catalyst to help Livingston Community Health deliver the best quality of care and excellent service to our patients and their families.
The Care Coordinator, in alignment with the goals of Livingston Community Health will be primarily responsible for patient care management. This position will provide ongoing support for the patient and team-based care model. The Care Coordinator will work with Operations, Nursing and Quality Improvement personnel to disseminate and collect information related to patient care. The coordinator will work closely with care team members to assist with patient self-management, data collection, case management, continuity of care and referral coordination. The Care coordinator will be responsible for regularly reporting patient care-management data and findings with the relevant departments.
Essential Functions, Duties, and Responsibilities
Manage an assigned panel of providers, monitor and close gaps of care. Work in collaboration with team members to identify care needs and maintains patient care database to track the delivery of care/services related to Care Based Incentives (CBI) QI measures; (e.g., Healthy Weight for Life (HWFL), Staying Healthy Assessment (SHA), Initial Health Assessment (IHA), Well-child visits, Diabetic Retinopathy Screening (DRS)) and overdue health maintenance care/services. Work with health plan care gaps and partner with health plans on specific projects to close care gaps. Interface with hospital health care systems and Managed Care Plans coordinate patient care after ER/ED visit or admission/post-discharge. Manages patient no-show list(s) and schedules patients accordingly. Provides required telephonic weekly/monthly engagement with patients or care teams. Population Health Management Provide telephone outreach, letters and education based on monthly registry; (i.e., for high-risk patients to review plan of care as indicated on providers last note, review medication compliance, blood glucose monitoring, diet/exercise etc.) Coordinate with the care-teams, operations team, outreach, and other departments to enhance patient care and utilization. Pre-flow the daily appointment schedule and Care Team Huddle Report to scrub for immunization, annual physicals, well child visits or any due, or past due, gaps in care that need to be addressed. Attends and actively participates in all meeting and educational updates and other activities as required or assigned. Attends workshops/seminars as necessary to increase skills and knowledge to provide effective care, treatment, and leadership. Develops and establishes working relationships with multiple departments to ensure cohesive communication, direction, and completion. Assist and support other QI activities as needed. Coordinate, track, and monitor data to assess outcomes of case management. Develop and maintains positive collaborative relationships within the organization and amongst community partners. Attends routine QI Team meetings and other meetings as needed. Maintains continuing knowledge and practice of competence by participating in continuing education opportunities facilitated by professional organizations. Other duties and projects as assigned.
Education, Knowledge, Skills, and Abilities
Education:
High school diploma/GED required; Associate degree preferred.
Knowledge, Skills, and Abilities:
Bilingual English/Spanish preferred. Knowledge of medical terminology preferred. Minimum of 3 years experience in clinical setting/FQHC. Leadership Communication with persons of all; ages, socio-economic backgrounds. Maintain a solid sense of privacy and confidentiality. Problem solving and conflict resolution. Customer service. Time management/Prioritization. Familiar with chronic health conditions. Adapt to changing environments. Knowledge of basic anatomy.
