Clinical Care Coordinator RPM

Essen Health Care

Essen Health Care is the largest privately held, multispecialty medical group in New York, providing high-quality, compassionate care to some of the state's most vulnerable and underserved residents.

Founded in 1999, we've grown from a single primary care office into a network of 50+ locations offering urgent care, primary care and specialty services, from women's health to endocrinology and psychiatry. We also provide nursing home support, care management, and in-home care through our Essen House Calls program. Guided by a Population Health model, our team of 500+ providers deliver care in-person, at home, or via telehealth, ensuring patients get the support they need when and where they need it.

We're looking for talented, motivated individuals to join our growing team. Whether you're a medical provider, administrator, or operations professional, there's a career here for you. Join us in making a real difference in the health of our community.

Job Summary

The Clinical Care Coordinator (CCC) works in collaboration with the primary care provider and all other members of the care team to support chronic disease care management for high-risk, high-need patients in a manner that is medically appropriate and cost effective. As a patient advocate, the CCC is responsible for direct and indirect patient care, helps identify clinical and health-related social needs and connects patients with relevant community resources.

Responsibilities

• Conduct primarily telephonic communication with patients to support the provider in addressing patients' medical and social needs.
• Occasionally patients in their homes to support proactive and efficient care delivery.
• Serve as the contact, advocate, and informational resource for patients, care team, family/caregiver(s) and community resources.
• Facilitate patient access to appropriate medical and specialty providers.
• Educate and refer patients to community resources.
• Develop a comprehensive, collaborative care plan, based on provider treatment plan, evidence-based chronic care guidelines, and patient/family goals for patients to promote adherence to provider recommendations and instructions.
• Assist with and facilitate the transition of care from inpatient settings such as hospital, rehabilitation facilities and skilled nursing facilities to home.
• Address medication adherence.
• Complete daily tasks such as taking clinical notes, reviewing medical records, following up on care gaps, coordinating chronic disease care, and other duties as assigned.
• Provide education to patients, families/caregivers regarding resources for health care management, and condition exacerbations.
• Communicate changes in patient's status timely with the care team.
• Work with the Administrative staff to provide feedback that can assist in identifying and improving day-to-day operational processes.

Qualifications

• 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

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.