Ambulatory Care Coordinator - Padonia Care

The Care Coordinator's primary responsibilities are to oversee coordination of care activities for a defined patient panel and to promote population health management by breaking down barriers and providing community, social supports, and health resources to the patient in a primary care setting. The Care Coordinator will work cooperatively with the Practice Manager, Lead Physician, RN Care Manager and other members of the care team to best serve the needs of the identified patient panel. The Care Coordinator will serve as a resource specialist in the primary care setting.Education:

High School Graduate or higherExperience:

3 years Medical Office experience and experience navigating the healthcare systemSkills:

Knowledge of medical and insurance terminologySkill in oral and written communication to address inter- and intradepartmental concerns, solve problems and address conflictDemonstrated skill in problem solving using available resources in innovative waysSkill in providing customer serviceComputer and personal productivity skills to enable effective use of EMR, e-mail, the internet, word processing, spreadsheets, presentation and database packagesAnalytical skills necessary to prepare and interpret reportsNavigating the health care system and providing resources to patientsDemonstrate problem solving skills and the ability to research and evaluate innovative ways to use community resourcesPrincipal Duties and Responsibilities:

Actively manage a defined panel of patients. This will include, but not be limited to:Providing linkages to community resourcesAssisting in scheduling urgent and stat specialty and imaging appointments and obtaining follow-up recordsFollowing-up to ensure compliance with PCP recommendations, specialist visits, PCP visits, community resources and lab/x-rayFollowing-up with patient after hospitalizations/ER visits, in accordance with policies and proceduresExecuting standing orders for tests and preventative servicesAssess Social Determinants of Health (SDOH) for a defined panel of patients, assist patients with positive screens with accessing community supports and services, and engage in care planningAnticipate the needs of the defined patient panel by preparing for and executing a care team 'huddle'. This should include seeing that the necessary documentation and pre-visit planning is completed or requested before patient visitsWork with the care team to prevent unnecessary utilization through the following:Utilizing CRISP: Notification system for ED and hospital admissionsCommunicating with local hospitals to get the medical discharge summariesCollaborating with the RN Care Managers and Providers to come up with plan of care to reduce hospital visits for a defined patient panelWorking in collaboration with Inpatient Care Management and Coordination teams to ensure warm handoffs are provided for patients coming to the ED, hospital or who have recently been discharged from the hospitalEngage in patient outreach and care planning through frequent contact and communication with the care team, patient and family for defined patient panel; document outreachHandle urgent on-call patient needs after hours, as neededIn conjunction with the patient, physician, family and other members of the care team, the payer and available resources makes referral for transitions in care (such as, nursing home, rehabilitation and sub-acute care) and durable medical equipment for the patient population that he/she managesBuild relationships with local agencies throughout the community, to assist patients with getting the services they need:Local Health DepartmentHome Health AgenciesPublic TransportationMental Health ProvidersDrug/Alcohol Rehab FacilitiesHomeless SheltersSpecialistsRadiologyInsurance CarriersPrivate and not-for-profit businessesWork to identify and close gaps in care for a defined patient panel and work collaboratively with Centralized Care Coordinator to ensure seamless patient outreachMonitor population management data and reports to ensure patients' health and social needs are being addressed. Develop targets to improve and/or action plans for areas in need of improvementPrioritizes care management activities in order of greatest patient need and system need to achieve optimum quality and cost outcomes. Meet productivity standardsUtilize Quality Improvement plan for reporting and improvement strategies, (PDSA) and Lean Daily Management (LDM)Attend staff and committee meetings including office based Advanced Primary Care/PCMH meetings and care management meetingsCOVID-19 Vaccination

All applicants must be fully vaccinated against Covid-19 or obtain a GBMC approved medical or religious exemption prior to starting employment at GBMC Healthcare, to include Gilchrist and GBMC Health Partners.Equal Employment Opportunity

GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.

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