I. Position Summary The Medical Home Network model of care unites provider communities and diverse healthcare entities around a common goal: to redesign healthcare delivery and transform the way care is managed at the practice level. This position will report to the Manager of Care Coordination and performs duties involving direct patient care in accordance with established clinical policies and procedures. The position works under minimal direction with a high level of patient contact; communicating with patients, their families and clinical staff to coordinate patient care.
The Care Coordinator - MHN must be able to independently prioritize and accurately perform a variety of duties within several systems and Electronic Medical Records. Must be able to work independently and in a team environment. T he Care Coordinator - MHN will assist with managing patient care processes to include utilization management of medical care needs, patient and family education, discharge planning and follow-up care.
II. Competencies - The Care Coordinator - MHN must be able to work efficiently within multiple software systems.
- T echnological competency skills are mandatory (Word, Excel, Centricity, etc.)
- Accurate data entry skills with tracking, and organization of case management and care coordination programs.
- Flexibility with managing multiple projects and caseloads simultaneously and respond quickly when priorities change.
- Outstanding organizational skills.
- Critical thinker, problem solver.
- Patient focused.
- Ability to think independently and learn quickly.
III. Experience & Training - High School diploma or GED equivalent required.
- Certified Medical Assistant.
- Current CPR Certification.
- 2-3 years related direct public contact experience with emphasis on customer service, oral/written communication skills.
IV. Essential Job Duties & Responsibilities - Ensure timely follow up with provider post hospitalization / emergency room visit.
- Retrieve discharge summaries and copies of medical records.
- Accurately utilizes the Electronic Health Records and Practice Management System.
- Coordinate internal and external resources for patients.
- Directs member care within contracted network whenever appropriate.
- Coordinates care on members' behalf with multiple community services.
- Maintain member privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory and accreditation standards.
- Consistently demonstrate dependability and timely completions of all duties and assignments.
- Arrange or provide transportation.
- Travels to the FFHC and HRDI sites as necessary.
- Provide patient education and support.
- Perform Health Risk Assessment.
- Assist with referrals, transitions of care, community resources and scheduling appointments, if necessary
- Documents all aspects of care using the electronic medical record system.
- Adheres to the FFHC professional code of ethics.
- Appropriately evaluates patient indicators (risk screening, etc.)
- Effectively communicate patient care plans to Associate Director of Care Coordination and appropriate teams.
- Provides services with respect for the autonomy, dignity, privacy and rights of FFHC patients.
- Assist with referrals, transitions of care, community resources and scheduling appointments, if necessary.
- Provide disease specific and preventive care patient education.
- Compile reports, enter, track and monitor data.
- Participate in conferences and training as identified by Associate Director of Care Coordination.
- Actively participates in care management team meetings.
- Make home visits, if necessary to ensure patients are following their plan of care.
- Displaying excellent customer service by displaying courtesy, tact, and respect for others is essential in this role.
- Must be able to function with discretion and confidentiality always keeping in mind HIPAA requirements.
- Respond to all incoming and outgoing calls in a professional manner.
- Accurately record all patient information. Must be able to bend, reach, and/or lift to 10 lbs; frequent sitting.
Performs other duties as required or assigned, which are within the scope of duties enumerated throughout.
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