Care Coordinator II

Care Coordinator

Sea Mar Community Health Centers, a Federally Qualified Health Center (FQHC) founded in 1978, is a community-based organization committed to providing quality, comprehensive health, human, housing, educational and cultural services to diverse communities, specializing in service to Latinos in Washington State. Sea Mar proudly serves all persons without regard to race, ethnicity, immigration status, gender, or sexual orientation, and regardless of ability to pay for services. Sea Mar's network of services includes more than 90 medical, dental, and behavioral health clinics and a wide variety of nutritional, social, and educational services.

Position Summary This position is responsible for the coordination of care for patients with chronic conditions and behavioral health needs at point of care. As a member of the Clinical Care Team, the Care Coordinator will participate in daily huddles, identify the patient's needs according to protocols, and provide point of care services. The Care Coordinator is responsible for enhancing quality and patient-centered care at Sea Mar Community Health Centers.

Duties and Responsibilities As a mission-driven organization, the core values of, and the services offered at Sea Mar are based on the belief that everyone deserves to be respectfully treated in a way that preserves dignity and enhances selfworth. Sea Mar is an advocate for its clients and aims to achieve industry-leading, client-centered, culturally aware services. Sea Mar employees serve as an extension of this mission and demonstrate their commitment to an excellent client experience by:

• Understanding and empathizing with client needs
• Surpassing client expectations
• Demonstrating a high level of integrity
• Exhibiting compassion and commitment
• Advocating for social justice
• Taking pride in individual work as well as that of the team
• Continually learning to stay current with industry standards, best practices and technology

The following is a list of duties and responsibilities for the care coordinator:

Patient Care Coordination Job Description

• Participate in morning huddles to anticipate the patient's clinical, social and behavioral health needs.
• Work with the care team to identify gaps in care and work to resolve them using process improvement strategies.
• Provide brief interventions at point of care to assist patients with management of their chronic illness, address any social needs and link patients to behavioral health.
• Send letters and perform follow-up phone calls to patients for planned visits.
• Advocate for patient services with community, social service, and medical providers.
• Participate and coordinate care transitions for patients who have been seen in an emergency room and/or have been discharged from a hospital/long-term care facility.
• Connect patients to Sea Mar and non-Sea Mar resources as appropriate and track all resources available to patients. These services may include but are not limited to insurance enrollment, preventive health services, behavioral health, dental, and care management.
• Assist patients with ongoing self-management goal setting based on mutual goal setting and with emphasis on client decision-making utilizing motivational interviewing skills.
• Follow up with patient to evaluate their condition and address barriers to care plan.
• Track patient's adherence with plan of care in electronic or paper charts and communicate outcomes and recommendations to the primary care provider.
• Participate in group visits and planned visit events providing care coordination support.
• Disseminate information regarding care for chronic illnesses and/or mental health and behavioral issues to the clinical care team.
• Maintain indigent patient medication assistance program and dispense 340b medications and supplies depending on the clinic site.
• Exhibit excellent customer service skills by using active listening skills, greeting patients in a welcoming manner, making them their only priority when providing services and assist in meeting the patients' needs.
• Other duties as assigned by the Health Center Administrator, and/or the Health Education & Care Coordination Program Manager.

Quality Improvement

• Function as a point person within the clinic care team regarding chronic disease management and improvement activities to improve clinical quality measures.
• Identify patients for gaps in care that need to be addressed in the huddle.
• Organize monthly Health Home meetings by working with the Clinic Operations Team/Health Center Administrator, create the agenda and help facilitate the meeting.
• Track and promote quality improvement initiatives related to chronic care (chronic disease) and behavioral health integration.
• Submit PDSA activities to the Health Center Administrator on a monthly basis as part of the QI process.
• Work closely with care team members and hold team meetings monthly or as needed when implementing new systems.
• Collaborate with clinical care team to improve Patient-Centered Medical Home processes and provide documentation demonstrating performance.
• Generate reports for care teams to identify areas of improvement and monitor sustainability of each quality measure.
• Review the medical record for quality and utilization indicators according to the Quality Improvement Plan. Train new clinic staff on the Chronic Care Model and Patient-Centered Medical Home.
• Participate in inviting patients to set up their Follow My Health account and provide brief information about the benefits of it.
• Other duties as assigned.

Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must be able to work independently, prioritize workload, and meet deadlines.
• Must have critical thinking skills and maintain confidentiality.
• Excellent organizational skills and ability to handle a variety of tasks simultaneously.
• Knowledge of medical terminology and/or behavioral health topics.
• Strong decision making and prioritization skills.
• Ability to work respectfully and professionally with the community, patients, families and staff.
• Able to work effectively in a multi-cultural environment with a diverse population.
• Sympathetic, mature, responsible, and reliable.
• Strong patient engagement, interpersonal, and communication skills and ability to establish a therapeutic relationship with the patient.
• Knowledge of the Patient-Centered Medical Home Model and motivational interviewing skills a plus.
• Knowledge of evidence-based standards of care for chronic conditions and behavioral health issues.
• Knowledge of and proficient in Microsoft Word, Excel, PowerPoint, and Outlook.
• Ability to utilize and document relevant patient information the Electronic Health Record.
• Knowledge of community resources.
• Ability to work in a fast-paced community health care setting.
• Ability to think analytically and problem solve in a multidisciplinary team and independently.
• Ability to deal effectively with difficult people and situations.
• Ability to communicate effectively with diverse communities.
• Ability to manage time effectively and prioritize tasks.
• Ability to analyze patient care data.
• Ability to identify client learning needs and to assess client's knowledge, skill level and readiness for learning.
• Ability to maintain the privacy and security of sensitive and confidential information in all formats including verbal, written and electronic; and adhere to policies and procedures related to local, state, and federal privacy requirements.
• Excellent communication and customer service skills.
• Critical thinking skills.
• Ability to understand and implement process improvement activities.
• Bilingual in Spanish is strongly preferred. Other language skills may be considered depending on site needs due to the population that is being served.

Reasoning Ability

• Must be able to work independently, have good problem-solving skills and be open to change processes.

Education, Certificates, Licenses and Registrations

• LPN with experience in ambulatory care and/or BA/BS/BSW in health-related field with one year of experience working in community health, or, 4 years of equivalent experience. The LPN does not have to have an active license; this is a non-licensed position.
• This position must obtain Basic Life Support (BLS) CPR within 90 days of hire date and is required to maintain current BLS CPR throughout employment.
• NCQA (National Committee for Quality Assurance) Certification is a plus.
• Valid WA State Driver's License and proof of liability insurance.

Medical Screening Requirements

• Pre-hire and annual employee health screening required.
• Annual influenza vaccine required. Only exception is for employees with a medical or religious exemption approved by Administration. Employees with an approved medical or religious exemption must