Care Coordinator II

Care Coordinator II

The Care Coordinator II (CCII) plays a crucial role in onboarding and supporting the patient, including managing and coordinating their care plan. The CCII acts as a liaison between the patient or caregiver, primary care team, and external partners to ensure seamless communication and timely access to care. Primary responsibilities include working in tandem with the primary care team to coordinate healthcare services. The CCII assures continuity of care is maintained and optimized for the patient and their care team's well-being.

Estimated Hiring Range:

$28.81 - $35.22

Essential Responsibilities

Patient Communication

• Actively support an assigned panel of patients by providing timely complex care coordination for patients with physical and behavioral health care needs.
• Educate patients/caregivers on the services provided by Housecall Providers Primary Care.
• Escalate concerns to primary care team according to protocols.
• De-escalate high stress situations and complaints received and forwards to primary care team/leadership as appropriate.
• Coordinate referrals for supportive services, labs, diagnostics or other coordination of care needs as requested by the primary care team based on insurance, location, patient preference, and order type.
• Schedule patient visits for assigned panel of patients based on urgency, geographic location, appointment type, provider availability and frequency of visit standards.

Clinical Support

• Authorize prescription refills for non-controlled drugs if approved by clinician.
• Provide pharmacy support including verbal orders, when appropriate, to expedite or clarify medication fulfillment.
• Provide primary care coordination support to assigned panel of patients with physical and behavioral health care coordination needs.
• Review, process and approve incoming referrals; ensure all intake documentation is complete and clinically relevant.
• Assess service appropriateness using medical terminology and clinical guidelines; collaborate with clinicians/supervisors for complex cases or exceptions.
• Responsible for meeting with DME vendors to maintain relationships and problem solve.
• Manage DME orders, ensuring charting and all documentation requirements are met.
• Support providers and patients with DME appeal process and follow up to make sure DME is delivered.
• Coordinate complex care with support services and community partners, including but not limited to home health, hospices, according to the patients' plan of care.
• Effectively coordinate care for patients with chronic and serious illness with internal and external stakeholders.
• Coordinate with the care team to ensure consideration is given to unique needs in integrated planning and that physical and behavioral health care plans are timely and effective.
• Develop working partnerships with patient, family, caregiver and community care providers, payors regarding patient needs and care plans.
• Assist with transitions in care from multiple settings to ensure continuity of care and address urgent issues appropriately. Work with care team to ensure transition in care visits are scheduled according to protocols.
• Update hospice and home health regarding patient hospitalizations and transitional care visits.
• Act as a consult to other teams and roles (external and internal) for geographically specific resources.
• Assist patients, caregivers and families in establishing/engaging with providers by coordinating appointment and transportation, as needed.
• Arrange family and/or caregiver attendance at appointments, and interpreters as required.
• Provide information about appointments, care plans, medications, referrals, prior authorizations, DME requests.
• Identify risk factors and service needs that may impact patient outcomes and address appropriately.
• Utilize a trauma-informed approach to provide patient-centric physical and behavioral health care and support including a person-centered approach to communication, education, and care planning.
• Assist patients with moving through the continuum of care based on clinical/medical/behavioral health needs by collaborating with the PCP, Primary Care Clinical Team (PCT), palliative care and hospice teams.
• Use motivational interviewing to coach patients toward improved physical and behavioral health care behaviors and self-management.
• Coordinate clinicians' diagnostic and lab orders, including lab and diagnostic testing, medical supplies and equipment.
• Provide timely outreach providing education, follow up on labs or diagnostics or clinical instructions from a member of the primary care team.
• Implement physical and behavioral health care coordination plan in collaboration with the patient's care team, including patient, family, caregiver, internal team members, as well as external providers, case workers and other relevant parties.

Documentation and Other Duties

• Compile and document all patient interactions and support activities in an appropriate and timely fashion to maintain patient's medical record.
• Create and update EHR and CRM records with precision; ensure data completeness, accuracy, and timely entry.
• Analyze and collate documents from multiple sources to build a comprehensive patient chart.
• Participate in quality and organizational process improvement activities and teams when requested.
• Take initiative in proactively assisting teammates when work volumes are high or back up is needed.

Experience and/or Education

Required

• Minimum 4 years of experience in a healthcare setting, including experience with medical records system

Preferred

• Experience in a primary care clinic, home health, or hospice setting
• Minimum 1 year of experience in customer service

Knowledge, Skills and Abilities Required

Knowledge

• Advanced knowledge of healthcare language, including medical and/or behavioral health terminology, basic patient care and community resources
• Advanced knowledge of barriers to care such as language, cultural factors, transportation, ability to self-manage and psychosocial issues and bring those to the attention for the care team
• Knowledge of HIPAA privacy rules and regulations
• Advanced knowledge of basic conflict management and de-escalation techniques

Skills and Abilities

• Leadership skills, including the ability to organize work and train/mentor others
• Participate in work-related continuing education when offered or directed
• Excellent customer service skills, including the ability to interact professionally, patiently and courteously with staff, patients, families and vendors over the phone and in-person
• Employ motivational interviewing, healthcare teaching and coaching skills or has the ability to learn
• Advanced organizational skills, plus the ability to manage multiple tasks and timelines in a high-stress environment. This includes the ability to:
• Prioritize tasks, manage telephone calls with a professional demeanor, problem solve and stay focused
• Work independently and collaboratively
• Use good judgment, personal initiative and discretion to perform job responsibilities
• Ability to take initiative and utilize innovative techniques and ingenuity
• Advanced ability to establish and maintain effective communication and collaborative relationships with colleagues, departments throughout Housecall Providers and CareOregon, as well as external providers and community agencies
• Advanced Computer application skills, including MS Windows, Word, Excel and Outlook
• Detailed understanding of electronic medical record systems and the ability to integrate updates to those workflows on a regular basis
• Advanced ability to facilitate group discussion or case review
• Learn, focus, understand and evaluate information and determine appropriate actions
• Employ critical thinking and draw conclusions from conversations and written or computer-generated material
• Ability to communicate effectively with diverse staff and patients, their families and caregivers
• Ability to work effectively with diverse individuals and groups
• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
• Ability to hear and speak clearly for at least 3-6 hours/day

Working Conditions

Work Environment(s): Indoor/Office Community Facilities/Security Outdoor Exposure

Member/Patient Facing: No Telephonic In Person

Hazards: May include, but not limited to, physical and ergonomic hazards

Equipment: