Patient Care Coordinator - Remote

Position Summary:

This position will serve as a liaison between Special Needs Persons (SNP) members, the PMG, Health Plan, medical providers, behavioral health providers and Long-Term Support and Service (LTSS) providers.  The PMG Personal Care Coordinator (PCC) will identify and reduce barriers to members’ care, assist the member in locating and accessing resources and educate the member on the importance of accessing care promptly.  The PMG PCC will serve as the primary point of contact for the member and will be an integral part of the member’s interdisciplinary care team (ICT). The PMG PCC provides support to the member as they self-navigate the health care system.  The PMG PCC works closely with member’s case management team to resolve access, medical and psychosocial related issues.  This PMG PCC must be able to efficiently manage and prioritize a caseload of 400 members. 

Degree of Supervision:

This position reports to the Ambulatory Case Management Supervisor. This position works under the direct supervision of a licensed clinical professional to ensure optimal coordination of care for the OneCare members requires moderate degree of supervision to ensure tasks are appropriately prioritized.

Job Duties and Essential Functions: 

• Collaborate with Health Plan staff to ensure timely communication of member’s clinical information.
• Effectively interview members to determine strengths, problems, functional status, goals and need for specific services/resources.
• Remain knowledgeable of SNP benefit structure. Guide members in understanding and accessing the benefits they are entitled to under Medicare and Medi-Cal, through the Health Plan program. 
• Assist with coordination of member’s health care and social service needs both within and outside the Medical Group and Health Plan.
• Develop rapport, establish and maintain effective interpersonal relationships with internal and external contacts at all levels. Coordinate the timely resolution of member and Provider concerns.
• Communicate effectively, both verbally and in writing with individuals from varying cultural and ethnic backgrounds. 
• Facilitate communication of the member Health Risk Assessment (HRA) and initial care plan (ICP) to the primary care physician (PCP). 
• Coordinate and schedule the Interdisciplinary Care Team (ICT) meeting for the member with the appropriate Team members. 
• Complete ICT meeting proceeding notes in timely manner. Maintain filing of assigned ICT minutes and forward to Health Plan.
• Complete the member annual Plan of Care ensuring member, PCP, PMG, and Health Plan receive document copy.
• Notify member’s care team of key event triggers (ie. Transitions of Care, falls, unsafe home)
• Outreach to members to complete assessment when there are changes to a member’s health status (ie. key events). Collaborate with PCP and clinicians to document modifications to the ICP as appropriate. Ensure member, PCP, PMG and Health Plan receive copy of updated plan. 
• Communicate promptly to the Health Plan of member’s case notes, HRA, care plan and interdisciplinary care team (ICT) proceedings for integration into other Health Plan medical management programs.
• Assist member in meeting their preventive care goals (ie. HEDIS measures, Evidence Based Outcome Measure activities).
• Assist member with scheduling of appointments. Promote, foster and document member barriers and compliance with ICP. Document collaboration with clinicians on strategies, plans and outcomes for overcoming barriers.
• Facilitate referrals to LTSS, behavioral health and other community resources in collaboration with clinician and Social Workers,
• Initiate referrals to both internal and external care management departments and other department/government or community agencies.
• Facilitate warm transfers to member’s assigned case manager or social worker in accordance with member needs, when appropriate.
• Maintain accurate records and documentation. 
• Maintain and keep in total confidence, all files, documents and records that pertain to the operation of business of Conifer Value-Based Care.
• Attend all mandatory trainings.
• Perform all other job-related duties as it relates to the job function or as delegated by the management team.

Physical Requirements:

• Light physical effort (lift up to 10lbs).  Mostly sedentary work. Regularly needs to be able to bend, stoop and reach to file. Must be able to drive.

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment.  This may include, but is not limited to, the COVID-19 vaccination,