Clinical Care Coordinator (ACO- House Calls)

Clinical Care Coordinator (ACO- House Calls)

The Clinical Care Coordinator is a key member of the outpatient care team, responsible for delivering in-home clinical services to patients. Closer in function to a clinician than an MA, you will be responsible for conducting your own house calls, and managing care holistically for a defined panel of complex polychronic patients in collaboration with a doctor or APC. This role focuses on supporting patient care plans, coordinating with providers, and ensuring a high standard of care during house call visits. The coordinator serves as a liaison between patients, families, and healthcare professionals, helping to ensure seamless communication, proper follow-up, patient education, and creative problem solving to remove barriers to care. A driver is provided to assist with travel, allowing the coordinator to focus on clinical responsibilities and patient engagement.

Responsibilities include:

• Conduct in-home patient visits
• Provide clinical care to patients in their homes, including assessments, health screenings, and follow-ups as directed by the provider or care plan.
• Highlight care gaps and opportunities for clinical and nonclinical interventions that will help patients achieve better health outcomes.
• Ensure each visit adheres to quality standards and organizational protocols.
• Coordinate patient care plans
• Collaborate with physicians, nurse practitioners, and other healthcare team members to support individualized care plans.
• Monitor progress and make recommendations for care adjustments as needed.
• Patient education & support
• Educate patients and caregivers on disease management, medication adherence, and self-care techniques.
• Address patient questions and concerns in a compassionate and professional manner.
• Conduct medication reconciliation for our high-needs population who often struggle with polypharmacy issues, especially as they move among care settings.
• Documentation & reporting
• Accurately document all visits, assessments, and communications in the electronic medical record (EMR) system in a timely manner.
• Ensure compliance with all regulatory and organizational documentation standards.
• Coordinate services & follow-up appointments
• Suggest and implement clinical initiatives designed to help avoid unnecessary hospitalizations.
• Assist with referrals, appointment scheduling, and coordination of ancillary services such as labs, imaging, or home health, if needed.
• Follow up on pending results or care actions and relay relevant information to the healthcare team.
• Maintain communication with the care team
• Act as a liaison between patients, families, and the broader care team to ensure continuity of care and timely updates.
• Escalate clinical concerns to the appropriate provider as necessary.
• Ensure compliance & patient safety
• Adhere to all infection control policies, privacy regulations (HIPAA), and safety guidelines during home visits.
• Maintain necessary clinical supplies and ensure equipment is in working order.
• Transportation & logistics coordination
• Work closely with assigned drivers to ensure timely and efficient routing for home visits.
• Manage daily schedules to maximize patient access and minimize travel disruptions.

Qualifications include:

• Proficiency in both English and Spanish (additional languages a plus)
• Medical Degree (International or National)
• Successfully completed Essen Medical Clinical training
• The ability to work independently and exercise clinical judgment in interactions with providers, patients, and their families/caregivers
• Good bedside / telephone-side manner
• Good communication and computer skills, and cooperative attitude
• Salary Range: $20-22 / hr, plus a quarterly bonus based on ability to help patients avoid unplanned hospitalizations.

Equal Opportunity Employer

Essen Health care is proud to be an equal opportunity employer, and we seek candidates who desire to work in and serve an ethnically diverse population.