Care Coordinator ECM - Ambulatory

Care Coordinator ECM - Ambulatory

The Care Coordinator Enhanced Care Management (ECM) functions as a liaison between patients, providers, and the healthcare system. The Care Coordinator ensures that patient needs, discharge planning, and care coordination efforts are performed consistently with care management criteria. The Care Coordinator must understand and implement evidence-based services while adhering to patient necessity, levels of care, medical conditions, discharge plans, and medication plans. Duties may also include patient instruction, care orientation, navigation and coaching.

Care Coordination:

• Participates in the implementation of the Enhanced Care Management (ECM) program with the goal of ensuring that eligible Medi-Cal beneficiaries receive enhanced care management and coordination.
• Supports patient self-management of disease processes and promotes behavioral modifications self-intervention.
• Conducts home visits and street visits with ECM eligible Medi-Cal beneficiaries for enrollment and on-going services.
• Assists patients through the healthcare system by operating as a patient advocate and health systems navigator.
• Assists patients with navigating and accessing community-based services and support as needed to support healthy living.
• Coordinates continuity of patient care with external healthcare organizations and facilities.
• Coordinates continuity of patient care with patients and families/caregivers following hospital admission, discharge, and Emergency Department visits.
• Reports care barriers and challenges to physician or designee.
• Conducts comprehensive, preventive screenings for patients and/or assists all support staff in daily patient interactions as needed.
• Promotes clear communication amongst interdisciplinary care team members by ensuring awareness regarding patient care plans.
• Facilitates patient medication management based upon standing orders and protocols.
• Participates as a successful team associate supporting data collection, health outcomes reporting, clinical audits, and pragmatic evaluation.
• Participates in the evaluation of clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
• Collaborating with leadership to coordinate project plans including project timelines.
• Provide direction and support to the project team as required.
• Tract project deliverables using appropriate tools.
• Identify project risks and recommend appropriate resolutions.
• Projects defined: Metrics, Physician Dashboards, and Quality Metrics.
• Assists in creation and submittal of Medical Group invoices.
• Travel to MLKCH ambulatory, hospital, and administrative sites as needed to aid in patient care.
• Performs other duties as assigned.

Position Requirements:

A. Education

• High School Diploma equivalent degree (GED) required
• Bachelor's degree preferred

B. Qualifications/Experience

• One (1) year of customer service experience in a healthcare setting or similar preferred.
• Valid unrestricted CA Driver's License with proof of vehicle insurance. Must present both within 30 days of hire/transfer.
• A team player that can follow a system and protocol to achieve a common goal.
• Must complete annual Workplace Violence Prevention Program/Certificate, per hospital policy, during initial training/orientation but not to exceed 30 days from hire/transfer.
• Highly organized and well developed oral and written communication skills.
• Confidence to communicate and outreach to other community health care organizations and personnel.
• Demonstrates sound judgment, decision making and problem solving skills.
• Prior Cerner or Electronic Medical Record experience (preferred).
• Prior employment in healthcare facility and/or Street Medicine (preferred).
• Bilingual Spanish (preferred).

C. Special Skills/Knowledge

• Proficient to expert computer skills utilizing Microsoft Office especially Word and Excel
• Critical thinking
• Resourcefulness
• Leadership
• Knowledge of healthcare delivery systems