Care Coordinator II

Sea Mar Community Health Centers, a Federally Qualified Health Center (FQHC) founded in 1978, is a community-based organization committed to providing quality, comprehensive health, human, housing, educational and cultural services to diverse communities, specializing in service to Latinos in Washington State. Sea Mar proudly serves all persons without regard to race, ethnicity, immigration status, gender, or sexual orientation, and regardless of ability to pay for services.

Sea Mar's network of services includes more than 90 medical, dental, and behavioral health clinics and a wide variety of nutritional, social, and educational services. We are recruiting for the following position:

Sea Mar is a mandatory COVID-19 and flu vaccine organization
** Position Summary
** This position is responsible for the coordination of care for patients with chronic conditions and  behavioral health needs at point of care. As a member of the Clinical Care Team, the Care Coordinator will participate in daily huddles, identify the patient’s needs according to protocols, and provide point of care services. The Care Coordinator is responsible for enhancing quality and patient-centered care at Sea Mar Community Health Centers.

** Duties and Responsibilities
** As a mission-driven organization, the core values of, and the services offered at Sea Mar are based on the belief that everyone deserves to be respectfully treated in a way that preserves dignity and enhances self worth. Sea Mar is an advocate for its clients and aims to achieve industry-leading, client-centered, culturally aware services.  Sea Mar employees serve as an extension of this mission and demonstrate their commitment to an   excellent client experience by:  
• Understanding and empathizing with client needs  
• Surpassing client expectations  
• Demonstrating a high level of integrity  
• Exhibiting compassion and commitment  
• Advocating for social justice  
• Taking pride in individual work as well as that of the team  
• Continually learning to stay current with industry standards, best practices and technology  As a Sea Mar employee, the individual in this position commits to adherence to these values to their  utmost ability and endeavors to strengthen and embody this mission daily.  The following is a list of duties and responsibilities for the care coordinator:
Patient Care Coordination   
** Job Description*
* • Participate in morning huddles to anticipate the patient’s clinical, social and behavioral health needs.

• Work with the care team to identify gaps in care and work to resolve them using process   improvement strategies.

• Provide brief interventions at point of care to assist patients with management of their chronic   illness, address any social needs and link patients to behavioral health.

• Send letters and perform follow-up phone calls to patients for planned visits.

• Advocate for patient services with community, social service, and medical providers.

• Participate and coordinate care transitions for patients who have been seen in an emergency room   and/or have been discharged from a hospital/long-term care facility.

• Connect patients to Sea Mar and non-Sea Mar resources as appropriate and track all resources   available to patients. These services may include but are not limited to insurance enrollment,   preventive health services, behavioral health, dental, and care management.

• Assist patients with ongoing self-management goal setting based on mutual goal setting and with   emphasis on client decision-making utilizing motivational interviewing skills.  
• Follow up with patient to evaluate their condition and address barriers to care plan.

• Track patient’s adherence with plan of care in electronic or paper charts and communicate   outcomes and recommendations to the primary care provider.

• Participate in group visits and planned visit events providing care coordination support.

• Disseminate information regarding care for chronic illnesses and/or mental health and behavioral   issues to the clinical care team.

• Maintain indigent patient medication assistance program and dispense 340b medications and supplies   depending on the clinic…