Care Coordinator

Department Overview

The Care Coordinator (Team Coordinator) is vital to supporting the care team with clinical coordination, analytical, and administrative functions. Care coordination in panel management is the task of bridging gaps between patient care, specialists, labs, health maintenance and preventive care. This position independently supports a Care Team which has a panel of approximately 5,000 patients.

 

Team Coordinators are vital to the implementation of the innovative Patient-Centered Medical Home (PCMH) model at the Family Medicine at Richmond Clinic. Team Coordinators also play a significant role in care coordination and panel management, proactively gathering data, analyzing current processes, identifying steps for improvement, and optimizing team performance. This role is also essential to optimizing revenue and performing well in Value-Based Payment (VBP) models along with evolving accountability requirements in transforming the health care system.

Function/Duties of Position

Patient management

• Supports proactive panel management through patient outreach, data analysis and management of registry reports, and coordinating required care via seeking orders, authorizations and scheduling needed service.  Compiles other needed statistical data pertaining to patient care and clinical operations. Proactively schedules appointments. 
• Performs schedule scrubbing activities to ensure appropriate utilization and preparation, including telehealth and in-person visits.
• Follows up on no-shows and cancellations to improve patient outcomes and utilization.

Care coordination 

• Responsible for pre-visit planning and schedule scrubbing, including updating health maintenance needs and scrubbing charts daily.  Proactively schedules appointments as needed, responds to in-basket messages, and contacts patients via phone and mail. 
• Manages patient calls/messages to and from their care team; including notifications of test results, referrals, etc. Obtains medical records. 
• Enters orders for referrals, lab tests and results into the EMR.
• Assists in coordinating transportation and interpreter services as needed.

Communication 

• Provides information and education to patients and gathers information for specific visits.
• Prioritizes and responds to patient questions via MyChart, phone, email and fax in regard to scheduling and care issues within scope. Assists in MyChart sign-up and patient engagement.
• Retrieves and returns voicemails, faxes, hard-copy mail - including sorting through in-boxes (both paper and electronic).
• Escalates all issues outside scope as appropriate.
• Plans and coordinates meetings of the entire care team, including but not limited to pod meetings and micro-team meetings. Assists with process improvement (long-term, complex projects and short-term, focused projects) and identification of improvement options.

Documentation/Data management 

• Documents legibly, concisely, correctly and completely to ensure team can accurately assess the status of care needs. 
• Uses approved clinical resources and follows procedures appropriately.
• Participates, as assigned, with database input. Abstracts external records into EPIC.
• Issues patient safety alerts to providers and helps manage the patients affected.
• Monitors tracking tools and provides real-time updates as appropriate. 
• Initiates and implements processes to facilitate continual improvements related to data collection.

Required Qualifications

Two years’ experience in a hospital or hospital based clinic setting, AND

High School diploma or equivalent, AND 

Current BLS certification at hire, AND 

One of the following four: 

Completion of a nationally recognized accredited medical assistant training program, including a practicum (externship) of at least 160 hours, OR 

Successful completion of a formal medical services training program of the United States Armed Forces, OR 

Current Oregon Emergency Medical Technician (EMT) license (basic or advance) and national EMT registration with the National Registry of Emergency Medical Technicians (NREMT), OR

Current Oregon Practical Nurse License 

For those completing medical assistant training or formal military medical services training as referenced above in #1 and #2, the following is also required (Those qualifying under the EMT or LPN qualification are exempt from this requirement.) 

MA certification received from a nationally recognized and accredited certifying body, upon hire or by the completion of the probationary period or internal job change eval