POSITION SUMMARY:Works collaboratively with physicians, staff, and other health care professionals to assist staff to provide care coordination across the health care continuum for targeted patients within the physician office setting. Is an integral member of the health care team who works to ensure safety, best practice, and high quality standards of care are maintained across the continuum. Responsible for disease registry activities for the clinic's targeted patient populations. Responsible for assisting the clinic in identifying care opportunities for both populations and unique patients. Success will be measured by the results of the process and outcome performance measures of the population of patients in the clinic. Position requires ability to effectively communicate with patients in person and on the telephone.

ESSENTIAL FUNCTIONS/DETAILED DUTIES:

Population Management

• Oversees a chronic disease registry, assuring that the database is kept up-to-date, including data entry.
• Generate & utilize care gap reports to identify patients overdue for visits, labs, or referrals and arranging for follow-up services as appropriate.
• Identifying patients not meeting clinical goals, such as BP control or glucose control, and arranging for follow-up services by protocol or as appropriate.
• Generating patient, physician, and clinic level quality performance reports.
• Conducts pre-visit chart review of targeted patients & generates daily report of attributed patients.
• Identifies needed preventative health maintenance, immunizations, and chronic disease interventions.
• Oversees population health monthly tracking logs, assuring documents are kept up to date.

Coordination of care across the care continuum including:

• Assists as liaison with patients and their families to physicians, clinical staff, and other departments.
• Assists as a liaison with hospitalized patients and the clinic. Following up with patients by phone shortly after hospital discharge and/or Emergency Department visits.
• Acting as a liaison with specialty clinics.
• Proactively acts as patient advocate, responding to and working to resolve patient concerns.
• Assist patients in utilization of community resources & enrollment in assistance programs, based on their healthcare needs or identified barriers.
• Assists with a variety of tasks, including but not limited to, coordinating referrals and completing prior authorizations for patients, to ensure their needs are met in a timely manner.

Proficient in patient communication:

• Establishes a trusting and supportive relationship with patients.
• Practices within the scope of a Care Coordinator by referring the patient for assistance to the Care Manager or nursing staff as necessary.
• Demonstrates a genuine concern for the patient's welfare, is honest and sincere in communication. Is respectful of the patient's opinions, perceptions and beliefs.
• Utilizes effective communication skills through reflective listening skills; summarizing and mirroring the client's words to ensure clarity and understanding.
• Demonstrates an ability to work successfully with strong emotions, while maintaining a professional demeanor.
• Is clear, articulate and direct in sharing and providing feedback, using language appropriate and respectful to the patient, free of technical jargon.

Leader & Supporter of Quality and Process Improvement Activities

• Assess clinic needs and then collaborate with Care Manager, Director of Clinic Operations, and Director of Clinic Nursing on strategies to achieve individual clinic level goals such as quality and efficiency.
• Serves as a leader, actively participating in and/or coordinates committees as needed/requested.
• Communicates and coordinates with the healthcare team in the development of tools for optimal patient outcomes and report findings.
• Develops standard work and trains clinical staff on targeted population standards of care.
• Meets on a regular basis with the Care Manager for information sharing and continuing education activities.

POSITION QUALIFICATIONS:

• High School diploma or equivalent required.
• LPN or Medical Assistant strongly preferred.
• Knowledge of medical terminology required or the completion of a medical terminology course in the first year of employment.
• Six months of office experience, preferably in a medical setting.
• Strong computer and telephone skills.
• Strong communication skills with the ability to maintain and display professionalism with patients and staff.
• Ability to maintain a high degree of confidentiality.
• Ability to work with people in a courteous and collegial manner.
• Ability to perform multiple tasks simultaneously, as well as flexibility and adaptability to clinic needs.
• Must be able to change work priorities and cope with constant interruptions.