Integrated Care Coordinator

Job Description

Job Description

SUMMARY OF POSITION

The Integrated Care Coordinator supports a team-based care delivery model within a Patient-Centered Medical Home (PCMH) in a Federally Qualified Health Center (FQHC). This role is essential in facilitating seamless patient care across the continuum, enhancing access to resources, and closing care gaps. The ideal candidate, a Medical Assistant or Community Health Worker, will work collaboratively with an integrated care team to perform use of Azara DRVS to track patient metrics and risk stratify, post-visit follow-ups, and patient-centered interventions that promote continuity and quality of care. 

ESSENTIAL JOB RESULTS

• Preparing for patient visits by reviewing care plans, any outstanding orders, recent tests, referrals, release of information, outside records, and any outstanding care gaps. 
• Coordinating with care team members to ensure all necessary documentation, labs, and screenings are completed before the visit. 
• Identifying and addressing barriers to care, including transportation, scheduling conflicts, and health literacy needs. 
• Assisting in reducing or removing any medical or non-medical barriers to care as appropriate by using Vibrant Health’s designated Social Determinants of Health screening tool as a guide. 
• Participating in care team huddles each morning to facilitate communication with care team members to be adequately prepared for upcoming patient visits. 
• Conducting follow-up outreach to patients after appointments to ensure plan of care is followed.
• Monitoring and documenting patient progress, addressing concerns or connecting them to additional resources, services, or programs within the health center as needed. 
• Organizing and facilitating activities of care across the continuum, creating linkages to care and connection to external community resources and/or programs as needed. 
• Using Azara DRVS to track patient metrics and risk stratify.
• Assisting in the building and/or maintaining of relationships with community organizations to enhance patient access to resources that address risk factors and/or social determinants of health (ie: food, housing, transportation, or financial assistance). 
• Serving as a liaison between patients and care team members, ensuring open communication and collaboration. 
• Providing culturally competent outreach to patients and families to empower them to engage as active participants in their health.
• Assisting in closing care gaps by conducting outreach to inform and/or remind patients of needed screenings, immunizations, and follow-ups. Assisting with the scheduling of services as appropriate. 
• Working closely with Medical Assistants, Referral Coordinators, Nurses, Providers, and other Integrated Care team members to ensure well organized, highly coordinated, patient-centered care. 
• Participating in team huddles and meetings to discuss patient needs, share updates, and address barriers to care. 
• Supporting quality improvement initiatives by identifying opportunities to enhance care delivery and patient outcomes. 
• Open orders are to be tracked in accordance with our policy and procedures with status documented to completion.

• Accurately documenting all patient interactions, interventions, and outcomes in the electronic health record (EHR). 
• Tracking and reporting on key metrics related to patient engagement, care coordination, and quality improvement. 
• Carrying out Vibrant Health’s mission: We provide access for all to integrated and high-quality care that fosters health beyond our walls.

• Accepting and using supervision, direction and consultation to maximize available resources in the completion of work duties.

• Additional responsibilities will be assigned as needed to maintain and improve effective functioning of the department and to advance the mission of the organization.

• All job responsibilities will be carried out under the direction of the organization’s policies and procedures.

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

• Previous experience in a team-based care model, PCMH, or FQHC setting.
• Proficiency in use of personal computers and Microsoft Office Suite (Word & Excel) required.

Individual must have:

1. Strong interpersonal and communication skills with the ability to build trust with diverse populations. 
2. Knowledge of care coordination, chronic disease management, and community resources. 
3. Proficiency in electronic health records (EHR) and patient management systems. 
4. Excellent organizational skills and the ability to manage multiple tasks in a dynamic environment. 
5. Developed rapport with patients and their families, community and other health care personnel.
6. A professional and respectful demeanor.
7. Worked successfully within team environment and collaborate with other professional staff.
8. Demonstrated excellent customer service, helpfulness, and a positive attitude.
9. Demonstrated the ability to recognize, understand, and appreciate the value of cultural diversity. Demonstrate social and cultural sensitivity appropriate to ethnically and economically diverse patients and staff.
10. Ability to travel to all parts of the facility and throughout the community.

PREFERRED KNOWLEDGE, SKILLS, AND ABILITIES

• Medical Assistant Certification 
• Bilingual English and Spanish.

SUPERVISORY RESPONSIBILITY

N/A

 

Americans with Disability Specifications

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands and fingers to handle or feel objects, tools or controls; reach with hands and arms; climb stairs; talk and hear. The employee must frequently lift and/or move materials that may weigh up to 40 pounds.

Work Environment

Work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must have manual dexterity and experience to perform handwritten paperwork, recordkeeping, and filing.
• Prolonged sitting, standing, or walking may be required. 
• Frequent bending/stooping, squatting, reaching above the shoulders, twisting and turning, kneeling, and pushing/pulling may be required. 
• Employment is contingent upon successful clearance from Criminal, Kansas and Missouri Child/Elder Abuse and Neglect, Sex Offender background investigations, TB testing, pre-employment drug testing, and verification of Hepatitis-B immunization.
• Occasional evening and weekend availability is required.

Trauma Informed Care

At Vibrant Health, we understand that many, if not most, people have experienced trauma in their lives. We have made a commitment to trauma informed care and support and educate team members continued development of understanding of how trauma affects individuals and coping strategies. We expect employees to incorporate their understanding about trauma into interactions with our patients and families, clinic visitors, and with each other.

Equal Employment Opportunity

Vibrant Health is an Equal Employment Opportunity (EEO) employer and complies with all applicable federal, state, and local employment laws. Employment decisions are based on qualifications, merit, performance, and business needs. We are committed to maintaining a workplace where all employees and applicants are treated with fairness, dignity, and respect. We provide equal employment opportunities to all qualified applicants and employees without regard to any status protected by applicable law. Vibrant Health also complies with applicable affirmative action and veteran employment requirements as required by law. Qualified veterans and individuals with disabilities are encouraged to apply.