As part of a team of Clinical Care Coordinators and LVNs, serves as a clinical care coordinator by navigating the care of complex or high-risk patients. Initiates and responds to patient calls and provides health education. Interacts and collaborates with multidisciplinary care teams, which include providers, nurses, pharmacists, laboratory technologists, health coaches, and dieticians.

DUTIES AND RESPONSIBILITIES:

1. Coordinates patient care as determined by the provider when applicable. Works with the provider clinic staff and population health department to identify patients with high-risk diagnoses and ensures clinical guidelines are being followed.

2. Works with Navigation and Innovation Center to answer patient calls regarding clinical questions for clinical care coordination panel patients within their expertise. Forwards complex calls to LVN Clinical Care Coordinator when applicable.

3. Contacts patients directly regarding concerns/ clinical questions brought forth by the patient or provider. Responsible for ensuring that patients are made aware of health issues, concerns, and the way in which one could address them.

4. Available to coordinate resources for high risk/poor compliance patients as determined by the primary provider, clinical staff, and population health department.

5. Collaborates with primary provider and internal and external specialty services to optimize patient care and experience.

6. Contacts CommuniCare post-hospitalization, post-ER and postoperative patients regarding status and schedules appropriate follow up with CommuniCare clinical care team.

7. Reviews no show list and contacts patient regarding status and clinical plan.

8. Assists, initiate referrals, and coordinates transitions of care regarding hospitalization follow-up, palliative care, hospice, etc. Maintains knowledge of specialty and ancillary provider contract contents, to include exclusions and contract terms.

9. Enters timely and accurate data into the electronic medical record to communicate patient needs and to ensure complete documentation of patient visits and phone calls.

10. Provides exceptional customer service internally and externally. Greets each customer with appropriate introduction. Addresses concerns prior to end of interaction. Assists other departments as appropriate.

11. Performs other related duties as assigned.

JOB QUALIFICATIONS:

High School Diploma or equivalent required

One year experience in a primary health care setting required

Experience with EMR/EHR preferred

Ability to plan, organize and perform well under stress

Bilingual in English and Spanish preferred

Sensitive to the needs of the Center’s target population

Knowledge of personal computers to include internet/intranet navigations

Scheduled hours and/or work locations are subject to change

REQUIRED PHYSICAL AND MENTAL ACTIVITIES AND REQUIREMENTS:

Finger Dexterity: Using fingers to make small movements such as typing or picking up small objects. Normal fine and gross motor control of fingers and hands.

Talking: Frequently conveying detailed or important instructions or ideas accurately, clearly, or quickly.

Hearing: Able to hear average or normal conversations and receive ordinary information; hear whispered voice at five (5) feet.

Repetitive Motions: Frequently and regularly using the wrists, hands, and fingers.

Visual: Visual acuity necessary for the proper evaluation of a patient and to prepare or inspect documents or other materials. Ability to accurately view computer monitors

Physical: Sitting 20-30% of time and standing, walking 70-80% of time. Lift up to 25 lbs; push and pull up to 45 lbs. Able to bend at the waist, twist and turn along axial plane.

Education

• High School/GED or better in General Business