Care Coordinator; PCMH - Reach LLC - Bilingual

Position – Care Coordinator (PCMH) - Bilingual Preferred
REACH and GROW Clinics, LLC
$24.7687 - $30.4624 hourly

Must upload with application MA Diploma (State Cert if MA-C), BLS through AHA.

Job Description

Responsible for coordinating care of the patient/family across the health care continuum. Through multidisciplinary collaboration, care is individualized to enhance achievement of mutually set goals and assure effective and efficient use of resources within fiscal realities. Serves as the link between the patient in the community and the primary care physician to promote seamless, quality care that enhances quality of life.

Serves as a broker in obtaining identified resources for the client; focuses on changing from retrospective, episodic case management to a prospective system of health maintenance, disease prevention and management. Responsible for assigned acuity level calls to maintain call ratios. Determine patients compliance to meet program obligations and provide decision support for managed care issues. Performs other clinical and clerical duties as needed.

Our case managers will be an advocate to help guide the patients through all aspects of their care needs.

Key Responsibilities

• Manages assigned case load (usually divided based on patient medical acuity levels)
• Ensures contact (or contact attempts) for patients within case load within program established time frames (High Medical Acuity, every 7‑14 days; Medium Medical Acuity, every 14‑21 days, Low Medical Acuity, every 30 days) in order to follow up on how the patient has been doing since their last appointment, addresses any requests or concerns that the patient may have. Contacts are mostly over the phone, but can be in‑person as well.
• Coordinate with medical providers on refill requests or questions regarding medication
• Collaborate with other care team members regarding needed or pending services (i.e. referrals, completing documents/forms, lab/x‑ray orders, etc.)
• Ensure patient has upcoming appointments scheduled based on program requirements, schedule appointments if needed
• Potentially request medical records from outside organizations in preparation for upcoming appointments
• Submit and renew PCS forms to health plan as needed for patients who require transportation services to appointments
• Order food baskets from community food bank for patients who demonstrate the need, and coordinate with patient for pick‑up time
• Perform new patient orientation for PCMH program
• Create care coordination case in EMR for documenting and tracking case progress
• Document all care coordination efforts in EMR
• Coordinate effort to create personalized Health Action Plan (within first 90 days of enrollment) for each patient within case load to establish appropriate goals for patients to work toward while they participate in the program. Input must be gathered by case manager from all members of the care team (physician, behavioral health specialist, and any appropriate CBO service providers)
• Collaborate with Kern BHRS for patients who meet medical necessity for behavioral health services
• Lead Interdisciplinary Care Team (ICT) meeting for patient to meet with care team to endorse final version of Health Action Plan
• Send contact and/or warning letters for non‑responsive patients
• Prepare evidence for patient non‑compliance and present in Interdisciplinary Team (IDT) Meeting. If patient is recommended for dis‑enrollment, send documentation and evidence to health plan to initiate dis‑enrollment
• Monitor daily file received from health plan that shows patients who contacted the health plan’s 24/7 nurse line, contact patient to follow‑up and schedule an appointment if necessary
• Monitor daily file received from health plan that shows patients who visited ED or had an inpatient stay, schedule hospital follow‑up within 7 days of discharge
• Maintain current and accurate program census
• Follow‑up and support patients identified as homeless or at‑risk of homelessness as they work to acquire and participate in housing services through outside organizations
• Cross‑train in front and/or back office positions (registration, vitals, injections, procedures within scope of practice,…