Description

SUMMARY:

The Lead Care Coordinator serves as a link between the patient and the healthcare organization as well as coordinating services with leading the care management team. The Lead Care Coordinator assists with meeting health care metrics alongside the Lead Care Manager. Coordinates and guides the patient through their Social Determinates of Health (SDoH) plans and ensures that they are following the best practices to lead a healthy lifestyle. A partner to the patients that makes sure their disease is managed by keeping track of diet, exercises, and medications along with connecting both primary care and specialty care services to optimize health care outcomes. 

 To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  

 
DUTIES AND RESPONSIBILITIES:

•   Acts as peer support for enrolled patients which includes advocacy as patients navigate the medical system and relationship building with individuals and their families
•   Assists with onboarding new Care Coordination staff members during initial employment 
•   Obtains statistical reports for Lead Care Manager on Care Coordination documentation 
•   Coordinate any patient caseload concerns from Care Management staff 
•   Reports any identified health care challenges to the site Care Manager 
•   Administers Health Risk Assessments (HRA) and assists with distributing any approved disease specific education to identified patient panel
•   Provides reminder phone calls for various scheduled appointments or follow up after scheduled appointments 
•   Assists patients with obtaining Primary Care Provider visits, specialty care visits, and ancillary services such as labs/diagnostics including making appointment as needed
•   Enters and maintains electronic records, compile reports and completes other program documentation in a timely manner (ex. progress notes, incident reports, unable to reach letters, HRA attempts, etc.)
•   Obtains copy of medical records such as ER discharge summary if requested or summary of specialty office visits to provide to Primary Care Provider
•   Attend individual care team meetings to provide support to the Care Coordinators with program progress and attend any Medical Home Network meetings/trainings 
•  Assist with tracking clinical outcomes and preventative health care ‘pay-for-performance’ services (HEDIS) throughout the year 
•  Identify and assist care team to re-engage patients who are not participating in the disease management programs if applicable 
• Handles and assesses crisis situations and coordinates to appropriate team member (ex. Care Manager, Provider, Behavioral Health, 911, etc.) 
•  Handles protective health information in a manner consistent with the Health Insurance Portability and Accountability Act (HIPPA)
•   Other duties and responsibilities as directed 

 This position requires compliance with all of Alivio’s written standards, including its Standards of Conduct, Joint Commission standards, all policies and procedures and Corporate Compliance requirements.  Compliance will be considered as part of the regular performance evaluation.

 SUPERVISORY RESPONSIBILITIES:  

•  None

KEY INTERRELATIONSHIPS:

WORKING CONDITIONS:

OSHA Category 3 – Involves no regular exposure to blood, body fluids, or tissues, and tasks that involve exposure to blood, body fluids, or tissues are not a condition of employment.

QUALIFICATIONS:

• Education:
  Minimum Associates Degree, Bachelors Degree preferred, or a combination of education and related experience. 

• Licensure:
  None

• Experience: 5 years or more in health-related experience as a Community Health Worker

• Special Training: None

•  Demonstrated Competencies:

 Must be bilingual – Fluent in English/Spanish

Proficient in Electronic Medical Record, MHNConnect

Microsoft Word and Excel

Exceptional organizational and interpersonal skills with attention to detail required

Strong oral/written communication skills 

Ability to work collaboratively in a team and manage multiple priorities, utilize effective time management skills, and exercises sound administrative and clinical judgment 

Demonstrate ability to work well with people of various ages, backgrounds, ethnicities, and life experiences. 

Previous experience in community outreach setting/ health care setting highly preferred.