Care Coordinator - ECM

Who We Are:

SAC Health empowers our patients and their families to live vibrant and healthy lives through culturally responsive, exceptional care. Patient-centered, whole-person care. Our unique, full scope, team-based approach is what makes SAC Health the provider of choice for patients.

Top-Tier Patient Satisfaction Scores | Largest Teaching Health Center FQHC | 11 Locations offering 44 Specialties | NCQA Patient-Centered Medical Home Level 3 Certified
Multi-Site Approved for NHSC & NCLRP loan forgiveness programs
- NHSC/Nurse Corps/Pediatric Specialty | HPSA Scores: Primary: 17 | Dental: 25 | Mental: 20

The Care Coordinator, ECM manages cases regarding utilization review, discharge planning, and patient services coordination. Collaborates with insurers, managed care organizations, referral providers, patients, and families to assist in developing case management guidelines.

Schedule: 5 days per week, 8 hours per day, Monday - Friday, Monday-Friday 7:30am-4:00pm |
Location: Brier Clinic, San Berardino, CA

• Performs intensive case management for a caseload of low to moderate risk patients with chronic medical, behavioral, or substance use health conditions.
• Collaborate with patients and the care team to build integrated plans of care to address medical, behavioral, and social support needs. Patient engagement will meet program expectations and ensure comprehensive, coordinated care.
• Participate in Systematic Case Reviews. Present patient needs in a prioritized and organized manner and assist in developing a plan of care for patients based on integrated feedback.
• Compile and analyze patient data/team data to provide prioritization and informed feedback to management. Will oversee patient/team databases and ensure accuracy of data.
• Actively monitor results to ensure appropriate follow-up and diagnostic studies are ordered and completed, as appropriate. Assist patients in following through on their care plan wellness goals, using both phone and in-person contact.
• Assist patients discharged from higher levels of care with transitioning to home. This may include medication reviews, referral follow-up, and linkage to external services. Perform transition of care assessments. Collaborate with the care team to ensure successful transitions.
• Work within a team of nurses, behavioral health clinicians, and patient navigators to ensure patient health needs are met. This will include engaging patients, building rapport, and establishing trusting relationships with patients and their care teams.
• Maintain active collaboration with the care team and extended network of care providers. Effectively communicate across the health care continuum to ensure patient needs are met.
• Engage and enroll new patients into the program through in-person or telephonic outreach. Work with team members to ensure team caseloads meet programmatic expectations. Gain a thorough understanding of program eligibility and expectations. Assist patients in maintaining eligibility to participate in the program.
• Meet value-based measurement expectations through data-driven, measurement-based care. Utilize reports to prioritize and organize daily work.
• Home and/or community-based visits may be required based on patient and team needs; must have a reliable vehicle, valid driver's license, and auto insurance.
• Attend and participate in staff meetings, in-services, staff development, educational courses, workshops, and conferences.
• Other duties as outlined in the official job description.

• Education:
  
  High School Diploma or GED required. Graduation from a Certified Medical Assistant Program is required. Associate degree preferred.
• Licensure/Certification:
  Medical Assistant Diploma/Certificate and Current CPR/BLS certification (must be American Heart Association or Red Cross accredited program). Valid California driver's license, and auto insurance is required. As a requirement of this position, you must receive EPIC certification for the module you have been hired into.
• Experience:
  
  2+ years as a Medical Assistant or related field required.
• Essential Technical/Motor
  
  Skills:
  
  Must be proficient in MS Office Suite (Word, Excel, PowerPoint, Outlook). Must be able to use widely support internet browsers. Must have the ability to use variations of electronic health records and other various databases.
• Interpersonal
  
  Skills:
  
  Must have excellent communications skills both orally and in writing. Must possess the ability to communicate with and relate to a diverse group of people including patients, community, and other staff. Must have strong conflict and problem resolutions skills.
• Essential Mental Abilities:
  Must be flexible to perform a variety of tasks. Must be well organized and a self-starter. Must have strong analytical and problem-solving skills.
• Work Eligibility:
  Must be legally authorized to work in the United States on a full-time basis. Must not now or in the future require sponsorship for employment visas.

SAC…