Care Coordinator - Rural Health Clinic Dayshift

POSITION SUMMARY:

The Care Coordinator is responsible for the Chronic Care Management of both the RHC and Specialty patient population. The Care Coordinator will collaborate care to create a more cohesive, streamlined experience for the patient between healthcare providers.

DUTIES AND RESPONSIBILITIES:

Implement and maintain an effective tracking system to identify, monitor, and manage patients eligible for Chronic Care Management.

Identify, engage, and actively manage patients who may be eligible for Care Management services, including PDCM, and CoCM, to support improved patient outcomes and care coordination.

Identify and actively manage patients with diabetes who would benefit from additional education, support, and care coordination services.

Implement an effective tracking system for quality-of-care measurement performance.

Become the leader on care measurements for all patient payers and provide guidance to providers and staff on what information should be addressed and gathered and how to better guide patients to meet measurable outcomes of health care.

Coach patients/families toward successful self-management of their chronic disease.

Utilize tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care through assessment, communication, care plan development monitoring, and modification.

Promote health behaviors in all populations and ensure navigation assistance with community resources.

Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialist (e.g., Diabetic Education).Cultivate and support primary care and specialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions in care and referral.

Serve as the contact-point, advocate, and information resource for patient, family, care team, payers, and community resources.

Develop systems to support workflow and prevent errors.

Facilitate and attend meetings among and between patients, families, care team, payers, and community resources as needed.

Attend and participate in training and meeting activities related to care coordination (e.g., PDCM training, CoCM training, cohort calls with other care coordinators).Demonstrates appropriateness in meeting objectives in age-specifics.

Perform other duties as assigned.

QUALIFICATIONS:

Current Licensed Practical Nurse (LPN) or Michigan Registered Nurse (RN) License preferred.

Certified Medical Assistant (CMA) will be considered.

Previous experience in caring for chronic disease patients required.
3-5 years’ experience in clinic or community health settings preferred.

Previous Care Coordination, Case Management or Home Health Experience preferred.

Demonstrated evidence of essential leadership, communication, education, collaboration, and counseling skills.

Proficiency in communication technologies.

Effective organizational skills and demonstrates the ability to maintain accurate notes and records.

Previous experience with health IT systems and data reports preferred.

Business background knowledge of Excel and Cerner.

Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.

Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers as required.

BLS Certified