In this role, the Care Coordinator Provides logistical and clinical monitoring support to assist the Care Manager in advancing the clinical aspects of Patient Centered Medical Home. Coordinates care across internal and external treatment providers to assure timely exchange of health care information both into and out of the system.
• Interacts with involved departments to negotiate and expedite scheduling and completion of tests, procedures, and consults.
• Executes internal and external referrals to assure timely care for patients.
• Provides targeted patient education.
• Follows-up with patients after an emergency room visit or hospital discharge.
• Handles non-appointment related calls from patients. Resolve the reason for the call or route to the appropriate party.
• Provides an effective communication link between patient and medical staff, including relaying messages from providers, gathering information from patients for providers, etc.
• Assists patients and providers in the medication refill process.
• Ensures that all patients are tracked and data entered into systems for follow-up and reporting. • Assists in coordination of care with pharmacies, insurance companies and other providers in the community and ensures that information goes when and where it is needed.
• Participate in team decisions regarding data requirements for pro-actively managing the team’s panel.
• Uses and updates the directory of resources in the service area to meet basic health and human needs. Be facile at using the resources available within the system.
• Acts as a back-up to other Care Coordinators or to other Care Team members as needed.
• Carries out other duties as assigned.
• Current unrestricted license to practice as a Medical assistant. (Preferred)
• Two (2) years experience in a healthcare arena or Six (6) + years experience in lieu of degree will be considered
• Preferred general or community health nursing experience.
• Mental and physical health sufficient to meet the demands of the position.
• Must be able to adhere to all client related policies and procedures
• Requires a valid Texas Driver's License, appropriate driving record and auto liability insurance that meets the minimum required by State or Texas statute
• Knowledge of advanced principles of health promotion, prevention and motivation
• Knowledge of protocols in general and an ability to quickly gain specific knowledge of the Center’s current operational protocols
• Knowledge of medical terminology and appropriate abbreviations
• Thorough knowledge of the Texas Nursing Practice Act
• Ability to read and comprehend medical instructions, short correspondence, and memos
• Ability to document, with clarity, all information relevant to a patient’s needs
• Ability to effectively present information in small group situations to patients, Center staff, and the general public
• Ability to prepare statistical and administrative reports
• Ability to work cooperatively with community agency personnel to coordinate services for patients
• Ability to use office equipment including but not limited to computers, fax machines, telephones and copiers
• Ability to prioritize and allocate resources