Job Description

The Patient Care Coordinator plays a pivotal role in care coordination and healthcare service management for the Medicare patient population within the primary care practice. Collaborating closely with healthcare providers, the Patient Care Coordinator ensures seamless transitions of care and supports follow-up engagement of high risk or vulnerable patients within the practice. The Patient Care Coordinator duties involve patient-facing tasks, facilitating smooth communication, support, and assistance throughout the patient's healthcare journey. The position demands a comprehensive understanding of clinical care delivery, coupled with robust communication abilities, all aimed at elevating patient satisfaction and care quality. This is a hybrid role with approximately 80% remote work and periodic working hours in supported clinics. ESSENTIAL FUNCTIONS Responsible for coordinating care management activities: Collaborate with clinical teams to ensure comprehensive care for responsible patients, including pre-visit planning and retrieval of post-discharge summaries. Serve as an essential conduit of information flow between healthcare entities and our care teams and systems. Engage patients in health improvement activities and educate them on self-management tasks to avoid unnecessary ED visits and hospitalizations. Support team huddles to enable clinic team to review active hospital census and population health data to close gaps in care, identify high risk patients in need of a visit, and review utilization trends. Actively manage a panel of high risk patients, anticipating their needs, addressing barriers to care, and coordinating with their attributed PCP care team to provide them access to care. Collaborate with patients, physicians, and care team members to assess progress toward health goals and ensure consistent documentation of patient self-management measures and progress. Maintain confidentiality and adhere to HIPAA regulations. Treat all individuals with dignity and respect. Participate in professional development activities. Responsible for coordinating care coordination services: Monitor various platforms to stay informed of patient utilization events such as hospital admissions, ED visits etc. and document occurrences. Perform and document transitional care activities, including 48-hour follow-ups post hospital visits, medication reviews, obtaining hospital records, and TCM visit scheduling. Collaborate with healthcare providers and staff to identify patients for care transition services. Support providers in regular engagement and scheduling for high-risk, complex patients. Collaborate with Medical Receptionists, Medical Assistants and clinicians to proactively identify gaps in care and risks that may lead to avoidable hospitalizations during patient visits. Coordinate with the PHP Care Management Team to escalate issues with C-SNP members in the office’s panel. Ensure patient’s health plan is flagged appropriately in the EMR, including flagging new C-SNP members. Provide clinical follow-up with patients as needed and offer guidance on effective care transitions. Support use of coding tools in the clinic during patient visits to capture chronic conditions. Maintain accurate and timely documentation of care coordination activities. EDUCATION and EXPERIENCE Preferred Qualifications: Active Medical Assistant Certification Or minimum of 3 years experience Minimum Qualifications: One (1) year medical experience in physician’s office Experience in Primary Care is highly desirable Acquainted with value-based care & Medicare Advantage preferred Preferred, but not required: Experience with care navigation or care coordination to include transitions of care support KNOWLEDGE, SKILLS and ABILITIES: Current Basic Life Support Certification Advance knowledge of medical terminology Supports practice mission and goals Bilingual Spanish may be preferred

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