Under the supervision of the Health Center Director, the Care Coordinator is responsible for the recruitment of, outreach to and the navigation and coordination of services for vulnerable patients living with complex health needs. Outreach activities will be conducted in primary care sites, homes, hospitals, and neighborhoods. The Care Coordinator serves as an integral member of an inter-professional care management team working alongside medical providers, nurse care managers and social service staff to meet the needs of our patients. The Care Coordinator will perform outreach and navigation services in a variety of Washington, DC settings, including the hospital, primary care clinics, patient homes, homeless shelters, and various other community settings.
MAJOR DUTIES/ESSENTIAL FUNCTIONS
The primary responsibilities of this position include:
· Utilizes strength-based patient-centered motivational interviewing techniques to build rapport and help patients improve their health.
· Participates in the development, maintenance, and adjustment of individualized care plans for patients that address both medical and social barriers to accessing care, and documenting accordingly in the EMR (medical record).
· Acts as a professional liaison between hospitals, primary care providers, specialists, community resources and Managed Care Organizations on behalf of patients to ensure patient-centered care coordination.
· Identify and track special populations including high-risk patients and other populations due for preventive or chronic care services Help patients obtain the care they want and need when they need it, which may include: assistance with financial/insurance options, solutions for transportation and translation services, , and/or removal or resolution of other barriers to care.
· Identify and track patients discharged from the inpatient service or the emergency department.
· Utilize team-based communication strategies to close the loop on referrals, hospital follow-ups and any outstanding items identified in the patient's care plan.
· Supports the primary care team by providing panel management to decrease the number of patients lost to care. Non-compliant in follow up care and disconnected from primary care.
· Identify which appointments may be made for patients before leaving the clinic and strive to get patients scheduled for those before they leave (e.g., mammogram and/or specialists).
· Identify opportunities to close gaps in care.
· Work with interprofessional team members to identify barriers to care with the goal of finding solutions and resources to remove the barriers to care.
· Assist patients with navigating the healthcare system including but not limited to working with pharmacies, social service agencies, and insurance agencies as well as internal services such as the lab and other discharge processes.
· Participates in interdisciplinary case conferences and team meetings.
· Provide culturally appropriate health education.
· Provide cultural mediation between communities and health and human needs.
· Communicate patient-related needs to appropriate clinical staff including those on the patients care team as well as those providing care coordination and care management services.
· Adheres to Unity's HIPAA guidelines and ensures the appropriate handling of sensitive information.
· Performs other duties as assigned within the scope of position expectations.
· High school diploma or GED. College coursework in business or health-related field preferred.
· Familiarity with community health, discharge planning, chronic disease management.
· Experience working as a part of an interprofessional team.
- Minimum of 2 years of experience providing care coordination services; experience in a hospital and/or community/outpatient setting preferred.
KNOWLEDGE, SKILLS AND ABILITIES REQUIRED BY THE POSITION
- Exceptional interpersonal and organizational skills, with attention to detail required; strong oral/written communication skills are a must.
- Exceptional computer skills (i.e., Microsoft Office Suite, EMR).
- Ability to work collaboratively in a team and manage multiple priorities, utilizes effective time management skills, and exercise sound professional judgment.
- Demonstrated ability to work well with people of various ages, backgrounds, ethnicities, and life experiences.
- Proven ability to work collaboratively and productively with clinicians, administrators, patients, and other individuals from various backgrounds and skill sets.
- Requires the ability to travel to multiple office locations.