Under the supervision of the Health Center Director, the Care Coordinator I is responsible for the recruitment of, outreach to and the navigation and coordination of services for vulnerable patients living with complex health needs. The Care Coordinator I serves as an integral member of an interprofessional care management team working alongside medical providers, nurse care managers, and social service staff to meet the needs of our patients. The Care Coordinator I 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.
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 high-risk patients that address both medical and social barriers to accessing care.
· 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.
· Identifies and tracks special populations, including high-risk patients and other populations due for preventive or chronic care services.
· Helps 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 removal or resolution of other barriers to care.
· Identifies and tracks patients discharged from the inpatient service or the emergency department.
· Uses 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 or disconnected from primary care.
· Performs outreach activities in primary care sites, homes, hospitals, and neighborhoods.
· Identifies which appointments may be made for patients before leaving the clinic and strives to coordinate care before patients leave (e.g. mammogram, specialists).
· Identifies opportunities to close gaps in care.
· Works with interprofessional team members to identify barriers to care, with the goal of finding solutions and resources to remove the barriers to care.
· Assists 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.
· Provides culturally appropriate health education.
· Communicates patient-related needs to appropriate clinical staff, including those on the patient's care team as well as those providing care coordination and care management services.
· With Support from nursing and social service staff, completes activities that helps inform the patient-centered care plan.
· 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.
· 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 (Microsoft Office Suite, EMR).
- Ability to work collaboratively in a team and manage multiple priorities, use 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 with diverse backgrounds and skill sets.
- Requires the ability to travel to multiple office locations.