Chronic Care Coordinator

Primary Purpose

The person in this position is a member of the Patient Centered Medical Home (PCMH) team where each team member plays an integral role in providing patient-centered health care. The incumbent is responsible in developing individualized person-centered care plans for patients with complex and chronic illness in accordance to KPHC's clinical care coordination model and evidence-based practice guidelines. S/he participates in healthcare innovation, leads projects, and activities that promotes quality patient care and improve health outcomes.

• Leads the PCMH practice team in team-based communication, planning, developing, and implementing care coordination activities to improve patient outcomes.
• Assess the needs of patients and facilitates referrals and care coordination with internal and external stakeholders as appropriate.
• Establishes person-centered care plan in collaboration with the patient and provider following NCQA-PCMH guidelines.
• Identifies gaps in the care of the patient and ensure that gaps are closed in alignment with NCQA-PCMH, HEDIS, and health plan requirements.
• Executes effective interventions to reduce inappropriate ER visits or length of hospital to improve care and reduce costs.
• Provides staff training as it relates to care coordination and chronic diseases as appropriate.
• Organizes and coordinates chronic disease patient classes such as diabetes, asthma, CKD, memory clinic, etc.
• Works in concert with other internal and external teams to achieve the goals and objectives of the Patient Centered Medical Home
• Implements policies, procedures, and processes developed by the PCMH team.
• Ensures that KPHC's PCMH team asserts changes based on the components of the chronic care model, KPHC and PCMH standards and guidelines for improvements.
• Provides oversight to support staff assigned to assist in care coordination activities.
• Prepares monthly report and updates to the Director of Clinical Operations as appropriate.
• Assist the Director of Clinical Operations in quality improvement and data validation activities as appropriate.
• Serves as a liaison for care coordination to insurance companies and other organizations as appropriate.
• Explores community resources and establishes partnerships to facilitate improvement.
• Supports other multi-cultural projects to enhance the delivery of patient care.
• Performs direct nursing care such as triage, nurse advice and floor duties and/or covers other departments as necessary.

The person in this position is a member of the Patient Centered Medical Home (PCMH) team where each team member plays an integral role in providing patient-centered health care. The incumbent is responsible in developing individualized person-centered care plans for patients with complex and chronic illness in accordance to KPHC's clinical care coordination model and evidence-based practice guidelines. S/he participates in healthcare innovation, leads projects, and activities that promotes quality patient care and improve health outcomes.

• Leads the PCMH practice team in team-based communication, planning, developing, and implementing care coordination activities to improve patient outcomes.
• Assess the needs of patients and facilitates referrals and care coordination with internal and external stakeholders as appropriate.
• Provides patient education, sets SMART goals.
• Establishes person-centered care plan in collaboration with the patient and provider following NCQA-PCMH guidelines.
• Identifies gaps in the care of the patient and ensure that gaps are closed in alignment with NCQA-PCMH, HEDIS, and health plan requirements.
• Executes effective interventions to reduce inappropriate ER visits or length of hospital to improve care and reduce costs.
• Provides…