MA Care Coordinator

Job Summary

• Provides care coordination to patients in the primary care setting in partnership with the primary care team. Serves in an expanded healthcare role to collaborate with providers, other members of the healthcare team, patients/families/caregivers to assist in the delivery of quality, patient-centered, and cost-effective healthcare services.
• Provides self-management support and patient education focused on prevention and optimal control of chronic conditions.
• Coordinates care across settings and assist patients/families/caregivers in understanding available healthcare options.
• Provides targeted outreach and interventions to avoid hospitalizations and emergency room visits. Responsible for navigating patients through transitions of care in the healthcare system, from inpatient services to outpatient services and to home, based on individual and patient population needs.
• Serves as a clinical resource to patients/families and works collaboratively with the interdisciplinary team to provide a continuum of care that minimizes fragmentation, is efficient, cost-effective, and achieves desired outcomes.

ROLE AND RESPONSIBILITIES

• Collaborates with providers and other members of the healthcare team to identify targeted patient populations within the practice site(s).
• Assesses the health care, educational, and psychosocial needs of the patient/family utilizing standardized assessment tools such as depression screening, functionality, and health risk assessment.
• Collaborates with providers, patients, and other members of the health care team to monitor the status of individualized plans of care and assist with targeted interventions as appropriate.
• Provides patient self-management support with a focus on empowering the patient to achieve optimal health and independence.
• Facilitates clinical interventions based on protocols and evidence-based clinical guidelines.
• Fosters a team approach and includes patients and their families/caregivers as active members of the team.
• Completes timely follow-up with patients discharged from the ED or Inpatient setting: Follow-up may include reviewing discharge instructions and medications, scheduling PCP or specialist follow-up appointments, coordinating necessary services/additional care/equipment/etc. during transitions of care, and problem-solving barriers.
• Demonstrates critical thinking skills, as well as positive relationship-building communication skills (both written and verbal).
• Maintains required documentation for all patient outreach and care coordination activities.
• Works with practice and leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance care coordination services.

SKILLS AND ABILITIES

• Demonstrates customer-focused interpersonal and communication skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families/caregivers.
• Demonstrates ability to work autonomously and be directly accountable for assigned duties.
• Demonstrates time management, priority setting, and work organization skills.
• Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.

QUALIFICATIONS AND EDUCATION REQUIREMENTS

• Current Medical Assistant Certification and/or Registration or LPN License preferred
• Critical thinking skills and ability to analyze data
• Excellent verbal and written communication skills
• Excellent interpersonal and facilitation skills
• Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities
• Demonstrates excellent time management, priority setting, work delegation, and work organization skills
• General computer knowledge and capability to use various computer programs