Community Health Alliance Job Description Care Coordinator Center for Complex Care

Transcription

1 Job Purpose: The Care Coordinator serves as an active member of the Community Health Alliance (CHA) Care Team, supporting the patient and the other Care Team members with patient management. The Care Coordinator exemplifies the Core Values of CHA. COMPASSION - ACCESSIBILITY - RESPECT - EXCELLENCE SERVICE. As defined by the Agency of Healthcare Research and Quality: Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care." Position Purpose: The is directly responsible for the population health management and patient engagement/care coordination of CHA patient for chronic health conditions. These duties include activities to enhance patient self-management, referral management, direct patient communications, patient engagement, data tracking and reporting, and assisting with resolving barriers to individual and system-wide access to services and resources. The must work to the ultimate goal of performing as part of the Care Team to improve access to care, quality of care and patient outcomes. The Care Coordinator will assist in the overall management of CHA s patients with chronic conditions Supervisor: Care Management Supervisor Education and Experience: Bachelor s Degree in health sciences, social work, public health or human services or a related field; experience in the medical field for at least two years; knowledge of community resources and processes; Bilingual Spanish preferred; training in database management, spreadsheet use; strong experience in customer service. Collaboration: Clinical leadership, Behavioral Health providers, Information Systems department, MA Supervisors, MA Trainers, Health Center Managers, community partners, funders. Directly reporting personnel: None Knowledge, Skills and Abilities: 1. Knowledge of the essential functions, practices and procedures of a medical clinic and office. 2. Knowledge of quality improvement processes. 3. Knowledge of an electronic medical record system. 4. Skill in operating personal computer utilizing word processing, databases, spreadsheets, and Skill in operating various office equipment: calculator, copy machine, fax machine, and telephone. 1

2 6. Ability to maintain confidentiality of information, patient financial and medical information 7. Ability to read, write legibly, calculate mathematical figures. 8. Ability to solve practical problems dealing with a variety of variables. 9. Ability to exercise good judgment in appraising situations and making decisions. 10. Ability to work and interact effectively and positively with other staff members to build and to enhance teamwork in the clinics and overall CHA organization. 11. Ability to communicate in a courteous and professional manner. 12. Ability to interview and communicate with patients in a clinical setting in Spanish (preferred). 13. Ability to understand and respond appropriately, effectively and sensitively to special population groups as defined by race, ethnicity, language, age, sex, etc. 14. Ability to hear and speak to converse over telephone and interview patients. 15. Ability to maintain a driver s license, and travel between clinic sites as needed. 16. Ability to lift up to 20 pounds on an occasional basis. 17. Reasonable accommodation will be made for physical limitations on an individual basis. Essential Care Team Responsibilities Care Management 1. Establish and maintain a trust relationship with patients and ensures patient confidentiality. 2. Coordinates the first contact with the patient upon referral from Care Team members. 3. Connects and coordinates patients to consultant services, external and internal resources, especially behavioral health, as needed as directed by Care Team members. 4. Maintains a current knowledge of community resources and maintains positive working relationships with those providing services; shares resource knowledge with Care Team members. 5. Assists with transitions of care especially in retrieving information from the patients other types of care settings including ER, specialists, or in-patient facilities. 6. Provides self-management and emotional support, compassion and is sympathetic to patient needs. 7. Assist patient in obtaining appointments for referrals when complex or when patient faces barriers. 8. Call patients in advance of visit with patient-specific reminders if necessary. 9. Reviews charts on all "no shows" and cancelled appointments per CHA policy and procedure. 10. Returns calls from patients, outside organizations and internal team members in a timely fashion. 11. Utilizes good time management skills to ensure all facets of patient care completed in a timely manner. 12. Consciously follows through on patient care needs, i.e., abnormal clinical results, etc. as a member of the Care Team in order to effectively manage patient care. 13. Documents all interactions with patients in medical record. 14. Treats all patients equally regardless of race, creed, gender, nationality, age or ethnicity. 2

3 15. Promotes health by educating the patient regarding diet, hygiene and prevention of disease. 16. On-going advocacy for patients and their families both internally and externally. Medical Quality 1. Ensures compliance with all CHA policy and procedures, HIPAA, OSHA & other regulatory agencies to ensure clinic and staff compliance. 2. Assist medical staff; completes and verifies medical assistant charting and referral work for outside testing and follow-ups. 3. Participates in quality assurance/improvement reviews projects as requested. 4. Participate in quality management projects; as requested. 5. Constantly alert for ways to improve customer service, improve patient flow, increase productivity, and improve utilization of resources communicating ideas to supervisor. 6. Adheres to policy and notifies supervisor regarding unusual occurrences, risk management issues, incident forms and/or patient complaints. 7. Attends and actively participates in team and provider meetings. Electronic Medical Record (EMR) and Electronic Practice Management (EPM) Responsibilities 1. Utilizes EMR communications template to include tasking to appropriate staff. 2. Utilizes reports generated from EMR and EPM system; when applicable. 3. Ensures competency in documenting, verifying and entering required information into EMR and EPM that pertains to position. 4. Provides EMR generated patient education materials as assigned by provider. 5. Identifies and reports documentation inaccuracies to clinical care team and supervisor. 6. Follows all policies and procedures pertaining to EMR. Professional Competence and Teamwork 1. Sets the example of exemplary customer service for both internal and external customers. 2. Professional respectful communication to create/maintain good relationships with supervisors and co-workers. 3. Fosters working together as a team: dealing with and resolving conflict in an timely, efficient and positive manner. 4. Actively participates in team meetings and provider meetings. 5. Utilizes proper dress and grooming habits as specified in the dress code. 6. Performs other duties as assigned. 7. Provides translation services to other referral providers as needed (as applicable) 8. Maintains and completes records, logs, timecards and reports accurately and timely in accordance with CHA policy and procedure. 9. Participates in community functions that represent CHA. Position Specific Skills for the Care Coordinator for Center for Complex Care: 3

4 1. Knowledge of population health management strategies and information systems for complex care and chronic disease management (i.e. EMR, database and spreadsheet software, etc.) 2. Knowledge of and ability to follow complex care and disease-specific management models as advised by the Care Team 3. Remains current on patient financial eligibility status. Works closely with community partners specific to complex care management issues. 4. Reviewing population health management data and patient registries to aid in care coordination decision-making 5. Discuss and make referrals to patient assistance programs such as Smoking Cessation, diabetes classes, etc. 6. Other duties as assigned by supervisor or Care Team. Job Standard 1: Confidentiality 1. Requires expeditious and accurate completion of tasks and projects assigned to allow the successful completion of individual and corporate goals. 2. Follow-through and follow-up with time-sensitive information for credentialing submissions, filing, and records retention. 3. Maintain confidentiality of records in accordance with HIPPA and CHA policy. Keep all files in a locked file cabinet or drawer. 4. Communicate with immediate supervisor as to progress and/or issues impeding progress for successful completion of any assigned task or project. Job Standard 2: Supports the culture of CHA 1. Works with minimal supervision as a team member in a self-directed environment, adhering to the mission and values of CHA. 2. Attends required department and organization staff meetings in order to be an informed employee. 3. Meets deadlines related to projects, regulatory and organizational policies and practices and as directed by immediate supervisor. 4. Represents CHA in a positive, professional manner effectively communicating the mission and values of CHA to both internal staff and external clients. 5. Willingness to learn new skills and continuously improve processes as needed or required. 4

5 Work Performance Standards Agreement Position: The preceding functions have been provided as examples of the type of work performed by employees assigned to this job position. Management reserves the right to add, modify, change or rescind work assignments and to make reasonable accommodations as needed. I understand that if I have any questions regarding any part of this position that I can ask my immediate supervisor or the Human Resources Director. I acknowledge that I have reviewed a copy of the job description and work performance standards as stated herein for the position of I acknowledge that I able to perform all the duties specified above. Employee Signature Date: 5