Part Time Care Coordinator I

Title: PT Care Coordinator

Department: Care Coordination

Status: Non-Exempt

Position Classification/Category: Care Coordination

Level: Beginner

Location:

Hourly Pay Range

Reports To: Population Health Manager

Direct Reports: N/A

Summary of Position

The PT Care Coordinator will be responsible for identifying and addressing gaps in preventive care and chronic disease management using electronic health records (EHRs), payer data, and clinical guidelines. The staff member will conduct patient outreach to schedule overdue services such as screenings, immunizations, and wellness visits, while also coordinating follow-up care after hospitalizations and/or ER visits. This position involves close collaboration with care teams members, primary care providers, and pharmacists to ensure that patients receive appropriate services in a timely manner. Additionally, the staff member will educate patients on the importance of recommended care, monitor medication adherence, and document interventions accurately to support performance metrics tied to value-based reimbursement. Success in this role directly contributes to improved health outcomes. Other duties may be assigned to suit the demands of patients, according to the respective location of the clinical site and the department.

Minimum Qualifications

Knowledgeable about major chronic conditions; including diabetes, obesity, and heart disease. A basic understanding of major community resources in Cabarrus and Rowan counties; including medical specialists, transportation, and other support services. Experience in collaborating with primary care, specialists, hospitals, home health, and other essential health agencies. Strong skills in critical thinking and motivational interviewing. Ability to support high risk and comorbidity patients. Ability to interact and render service impartially to diverse populations. An understanding of cultural competency, health literacy, and social determinants of health as it relates to promoting positive health outcomes. Interacts with respect and in a professional manner with patients, staff and external customers. Must be able to commute independently between CRCHC sites.

Experience: 1 year in a generalized public health care setting preferred or 1 year of experience in care coordination, discharge planning, or health coaching preferred.

Additional skills required: Knowledge of community resources; including social services, medical specialists, and other treatment programs. Excellent leadership and coaching skills. Strong computer skills with knowledge of Microsoft Office products. Excellent verbal and written communication skills. Able to work independently and in a multidisciplinary team. Able to effectively utilize an electronic health record to document all patient encounters.

Education: Associate degree in healthcare related field preferred.

Certification(s)/Licensure: Certified Nursing Assistant or Medical Assistant preferred

Physical Requirements

The physical demands described here represent those that must be met by an employee to successfully perform the essential functions of this job.

• Frequent walking, standing, and moving about.
• Frequently bends, kneels, and crouches.
• Repetitive movement of hands and fingers – typing and/or writing.
• Talk and hear.
  
  

Key Responsibilities & Duties

• Remains current on all Medicaid Managed Care benefits and eligibility requirements.
• Delivers courteous and respectful communication with staff, peers, and patients.
• Facilitate coordination of care for high-risk patients and/or targeted populations within a primary care setting
• Assist clinical staff in conducting care transitions for patients leaving the hospitals, including the coordination of care with primary care, home health, outpatient clinics, and skilled nursing facilities with supervisory support.
• Review electronic medical records and other reporting tools to identify at-risk patients.
• Identify community resources to reduce barriers to care, such as transportation services.
• Contact patients overdue for care and encourage appropriate follow up care.
• Contacts patients for COVID-19 management follow-up in accordance with workflow and policy.
• Participate in quality improvement activities by initiating or contributing to monitoring, measuring, analyzing, improving and/or controlling program goals, objectives and/or services.
• Assists QI initiatives to include events and outreaches (as needed).
• Assists with Panel management for patients looking to establish care.
• Support current incentive, regulatory, and certification requirements (such as Meaningful Use, PCMH and UDS) through documentation, participation in initiatives, and other activities as directed.
• Facilitates members understanding of the physician’s treatment plan, including but not limited to, prescription refills, medical supplies, referral authorization of services, and when to seek care with supervisory support.
• Interviews the member and/or family to further assess social, emotional, functional, and physical health status.
• In the interest of the business all bilingual staff are expected to translate.
• Other tasks as assigned