Care Coordinator

The Care Coordinator is responsible to collaborate with patients identified with vulnerabilities and potentially eligible for case management (e.g., post-hospitalization, un-controlled diabetics, multi-pharmacy) to assist them in developing and updating an individualized care plan. In addition, performing outreach to encourage adherence with evidenced-based guidelines to improve the health of the company's overall population. This position will support patients and their families in self-management and behavior change.

• Medical Assistant, Licensed Practical Nurse, or a Foreign Medical Graduate (MD) preferred.
• Minimum 3 years of related experience in a clinic or hospital setting.
• Knowledge of health care and managed care administration policies.
• Phlebotomy certification preferred.
• Must be knowledgeable of MS Office and EHR programs.
• Use relevant information and individual judgment to determine whether events or processes comply with laws, regulations, or standards.
• Ability to work independently and to carry out assignments to completion within parameters of instructions given, prescribed routines and standard accepted practices.
• Understand written sentences and paragraphs in work related documents.
• Actively look for ways to help patients.
• Knowledge of medical terminology.
• Bilingual skills preferred (English/Spanish or English/Creole).

• Ensures that completed screening and tests, specialist notes, and operative reports are filed correctly in the medical chart prior to the patient consultation with the clinician.
• Screens medical charts prior to visit for required HEDIS, 5 Star measures, and medical conditions to alert clinician on date of appointment.
• Receives HEDIS measures as indicated by health plans to ensure all metrics are met for each patient.
• Works with diagnosis data from health plans to ensure all chronic conditions are properly reported to avoid GAP periods.
• Monitors the referral process to ensure patient completed specialist visit and notes are received.
• Updates medication list, current problem list, and past medical history for every patient visit.
• Receives and makes patient calls to schedule/re-schedule appointments and provides instructions from primary clinician.
• Cultivates and supports primary care with timely communication, follow-up calls, and integration of patient information into the care plan.
• Participates in daily huddles with the clinical staff to review Medicare patients scheduled for the following day.
• Assists with the identification of "high-risk" patients based on chronic illnesses and special healthcare needs.
• Assists clinician with accurately documenting diagnoses in progress notes.
• Provides discharge instructions to patients, answers patient questions, and schedules follow-up appointments with PCP and in-house specialists, as needed.
• Assists clinician with medical assistant duties when needed.
• Performs other duties as assigned.
  At Clinical Care Medical Centers, we are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and employees without regard to race, color, religion, sex, pregnancy, national origin, age, physical and mental disability, marital status, sexual orientation, gender identity, gender expression, military and veteran status, and any other characteristic protected by applicable law. Clinical Care Medical Centers believes that diversity and inclusion among our employees is critical to our success as a company. We support an inclusive workplace where employees excel based on personal merit, qualifications, experience, ability, and job performance.