ECM Care Coordinator

JOB SUMMARY:

The MA ECM Care Coordinator primary responsibility is to administer care coordination and activities for the patients of the primary care teams who would benefit from care coordination. This will include developing and monitoring care coordination processes and supporting Nurses and primary clinical teams with these efforts. It will also include identifying insight of patient population in cooperation with the clinical informatics team and working directly with RN Case Manager, care teams, referral coordinators, community health workers, housing navigators, and clinical social workers, To ensure appropriate care management, as well as care coordination for target populations as described in Enhanced Care Management description of care. The MA Care Coordinator behaves in a professional manner, and consistently demonstrates and promotes the values of Community Health Systems, Inc.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Under RN Case Manager direct supervision, actively manages assigned panel of chronic care patients
• Responsible for working with patient and the patient's care team to coordinate change readiness, needs assessment and develop an individualized treatment care plan
• Maintains a minimum caseload of 40 patients per month.
• Responsible for working with patient and the patient's care team to ensure timely and appropriate care transitions for designated care coordination patients
• Responsible for coordinating with the clinic RN and the care teams to ensure a smooth flow for care coordination patients
• Under RN Case Manager direct supervision, assist patients in setting SMART goals for self -management, teaching them how to do self-management tasks and report abnormal findings to their physician team.
• Responsible for following up with designated care coordination patients and assessing the compliance with the SMART goals set
• Collaborates with the patient, physician, and other care team members in assessing the patient's progress toward individual health care goals
• Under RN Case Manager direct supervision, establishes barriers to care when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments
• Responsible for pre-visit planning workflow to ensure care completion prior to visit whenever possible
• Responsible for after visit care planning summary review with patients whenever appropriate
• Under RN Case Manager direct supervision, assist with development, procurement, and adoption of patient self-management educational resources used by the primary care teams for care coordination patients
• Involves the patients in activities to improve their health (patient engagement);
• Educates the patient about self-management tasks they can undertake to gain greater control of their health status.
• Under RN Case Manager direct supervision, being available to provide telephone advice to designated care coordination patients within their scope.
• Works with the clinic RN and the clinical informatics team to obtain, facilitate and report care coordination registry at the site & complete relevant documentation
• Maintain accurate and timely documentations within treatment care plans
• Works with the RN Case Manager and the clinical informatics team on quality measure/outcome reporting process for care coordination patients
• Develop relationship with patient as an integral member of team
• Provide follow-up contact with patient as indicated to ensure compliance with recommendations - medications, lab/x-ray, specialist visits, PCP visits, dieticians, etc.
• Stays informed about many aspects of the care coordination patient's care: referrals to specialists, hospitalizations, ER visits, ancillary testing, and other enabling services;
• Works collaboratively with referral coordinators and care teams to facilitate care coordination patients' care transitions
• Anticipate the needs of this patient population, seeing that necessary documentation and pre-visit planning is completed or requested before patient visit;
• Work collaboratively with community resource specialists to provide the designated care coordination patients with community resources available
• Provide clinical follow-up with care coordination patients per protocol when indicated
• Provide information and guidance to patients and/or family regarding effective care coordination and care transitions and enhanced patient-care team communication
• Guides patients through transition of care from inpatient hospitalization and ED visit to home care
• Participates in measuring clinical outcomes, analysis activities, and performance improvement.
• Maintains strict confidentiality; follow HIPPA regulations
• Treats staff, physicians, NPs/PAs, RNs, LVNs, visitors, patients and families with dignity and respect
• Participates in professional development activities
• Perform all other duties as directed either formally or informally, verbally or in writing.

SUPERVISORY RESPONSIBILITIES:

This position has no supervisory responsibilities.

KNOWLEDGE, SKILLS AND ABILITIES:

• Bilingual - English/Spanish preferred
• Knowledge of medical practice and care of patients
• Knowledge of examinations, diagnostic and treatment procedures,
• Knowledge of medical equipment and instruments
• Knowledge of common safety hazards
• Advance knowledge of medical terminology
• Ability to use good judgment and critical thinking skills; ability to identify and resolve problems
• Ability to interpret, adapt, and apply guidelines and protocols
• Ability to establish and maintain effective working relationships with patients, families, medical staff, and co- workers
• Ability to work independently, while collaborating with other team members
• Ability to self-motivate, prioritize, and be willing to invest in a change process to improve efficiencies
• Excellent written, verbal and listening communications skills both in English and Spanish
• Proficient computer skills - data entry, retrieval and report generation
• Ability to work with a diverse patients/family population

EXPERIENCE AND EDUCATION:

• Possession of a high school diploma or equivalent is required
• Active Medical Assistant certification (Preferred)
• Current Basic Life Support certificate
• Minimum 1 year of experience as a Medical Assistant in a primary care or community health setting, with exposure to care coordination, patient follow-up, and chronic care populations
• Experience in Primary Care with this population is highly desirable