Patient Care Coordinator - Future Focus Family Medicine

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Job Description:

The Patient Care Coordinator plays a pivotal role in care coordination and healthcare service management for the Medicare Advantage and ACO patient population within the primary care practice. Collaborating closely with healthcare providers, the Patient Care Coordinator ensures seamless transitions of care and supports adherence to treatment plans. 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 clinic-based position.

ESSENTIAL FUNCTIONS

Responsible for coordinating care management activities within the practice:

• Collaborate with clinical teams to ensure comprehensive care for all patients, including pre-visit planning and post-visit summaries.

• Engage patients in health improvement activities and educate them on self-management tasks to avoid unnecessary ED visits and hospitalizations.

• Facilitate weekly team huddles to review 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 chronic care patients, anticipating their needs and addressing barriers 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.

• Participate in regional and market level Patient Care Coordination and Population Health meeting to ensure standards are adopted  at the local practice.

Responsible for coordinating care coordination services within the practice:

• Collaborate with healthcare providers and staff to identify patients for care transition services.

• Support providers in referring high-risk, complex patients to the Complex Care Management team program.

• Collaborate with Population Health Specialists, Medical Assistants, and clinicians to address gaps in care during patient visits.

• Coordinate medication refills and collaborate with central Medication Adherence team in patient outreach to ensure patients with chronic illness take medications as prescribed.

• Conduct patient outreach to address gaps in care, medication adherence, and frequent ED visits.

• Coordinate referrals and utilization management events according to standing orders and Standard Operation Procedures (SOP).

• 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.

• Coordinate consults, referrals, prior authorizations, and follow-ups with community resources.

• Review and manage home health certifications and discharges with relevant providers to ensure appropriate utilization of the services

• Maintain accurate, up to date Inpatient (IP), Emergency Room (ER) and Home Heath (HH) trackers per Standard Operating Procedure.

• Coordinate with ACO Clinical Team to escalate issues with ACO members in the office’s panel.

• Ensure patient’s health plan is flagged appropriately in the EMR, including flagging new ACO members.

• Manage medication prior authorizations to ensure timely patient access to prescribed treatments.

• 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.

• Participate in measuring clinical outcomes and performance improvement activities.

• Offer backup support for medical assistant (MA) services within the clinic as needed, utilizing a team-based approach.

EDUCATION and EXPERIENCE

• Preferred Qualifications:  Active Medical Assistant Certification

• Minimum Qualifications:  One (1) year med