INTRODUCTION

Under the supervision of the Health Center Director, the Patient Care Coordinator (Internal & Family Medicine) is responsible for the recruitment of, outreach to and the navigation and coordination of services for vulnerable patients living with complex health needs. The position serves as an integral member of an inter-professional care management team working alongside medical providers, nurse care managers and social service staff to meet the needs of our patients. The position performs outreach and navigation services in a variety of Washington, DC settings, including the hospital, primary care clinics, patient homes, homeless shelters, and various other community settings.

MAJOR DUTIES/ESSENTIAL FUNCTIONS

Essential and other important responsibilities and duties may include, but are not limited to the following:

• Utilizes strength-based patient-centered motivational interviewing techniques to build rapport and help patients improve their health.
• Participates in the development, maintenance, and adjustment of individualized care plans for high-risk patients that address both medical and social barriers to accessing care.
• Acts as a professional liaison between hospitals, primary care providers, specialists, community resources and Managed Care Organizations on behalf of patients to ensure patient-centered care coordination.
• Identifies and track special populations including high-risk patients and other populations due for preventive or chronic care services.
• Helps patients obtain the care they want and need, when they need it, which may include: assistance with financial/insurance options, solutions for transportation and translation services, and/or removal or resolution of other barriers to care.
• Identifies and track patients discharged from the inpatient service or the emergency department.
• Utilizes team-based communication strategies to close the loop on referrals, hospital follow-ups and any outstanding items identified in the patient's care plan.
• Supports the primary care team by providing panel management to decrease the number of patients lost to care, non-compliant in follow up care and disconnected from primary care.
• Performs outreach activities in primary care sites, homes, hospitals, and neighborhoods.
• Identifies which appointments may be made for patients before leaving the clinic and strive to coordinate care before they leave (e.g., mammogram and/or specialists).
• Identifies opportunities to close gaps in care.
• Works with inter-professional team members to identify barriers to care with the goal of finding solutions and resources to remove the barriers to care.
• Assists patients with navigating the healthcare system including but not limited to working with pharmacies, social service agencies, and insurance agencies as well as internal services such as the lab and other discharge processes.
• Participates in interdisciplinary case conferences and team meetings.
• Provides culturally appropriate health education.
• Provides cultural mediation between communities and health and human needs.
• Communicates patient-related needs to appropriate clinical staff including those on the patients care team as well as those providing care coordination and care management services.
• Acts as liaison between patient and Primary Care Medical Home in resolution of problems or referral of appropriate resource.
• With Support from nursing and social service staff, completes activities that helps inform the patient-centered care plan.
• Adheres to Unity's HIPAA guidelines and ensures the appropriate handling of sensitive information.
• Performs other duties as assigned within the scope of position expectations.

Internal & Family Medicine Specific Duties:

• Responsible for the recruitment of, outreach to and the navigation and coordination of services for medically-complex and vulnerable patients.
• Serves as a member of an inter-professional "overlay" team composed of a Registered Nurse (RN) and a Site Program Coordinator. The team collectively manages care for difficult-to-reach patients and those that have higher levels of acuity, either because of health status or due to frequent utilization of the hospital system.
• Supports the development and implementation of care coordination processes alongside care management team including but not limited to Registered Nurses, Social Service staff and My Health GPS program staff.
• Manages a panel of complex, high-risk patients that are not well connected to care through outreach, scheduling of appointments, sharing in appointment visits and follow up of specialty visits.
• Provides care coordination and navigation of services for patients following ER visits and hospitalization.
• Performs home visits to recruit and maintain relationships with patients in need of coordinates care; complete community and home-based follow-up visits as needed.
• Perform community-based outreach activities and working with referring providers in a clinical setting.
• Builds positive rapport with staff on care teams.
• Mentors site-based Care Coordinators to improve quality of services delivered to patients.

MINIMUM QUALIFICATIONS

• High school diploma or GED. College coursework in business or health-related field is preferred.
• Two (2) years of experience providing care coordination service. Experience in a hospital and/or community/outpatient setting is preferred.
• Experience working as a part of an inter-professional team.

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES

• Knowledge of medical terminology, ICD10 and procedural codes.
• Familiarity with community health, discharge planning, chronic disease management.
• Exceptional interpersonal and organizational skills, with attention to detail required; strong oral/written communication skills are a must.
• Ability to work collaboratively in a team and manage multiple priorities, utilizes effective time management skills, and exercise sound professional judgment.
• Demonstrated ability to work well with people of various ages, backgrounds, ethnicities, and life experiences.
• Proven ability to work collaboratively and productively with clinicians, administrators, patients, and other individuals from various backgrounds and skill sets.
• Must have the ability to analyze data.
• Demonstrated proficiency with business software (i.e., Microsoft Office Suite, EMR).
• Requires the ability to travel to multiple office locations.

SUPERVISORY CONTROLS

The position reports directly to the Health Center Director.

GUIDELINES

The position abides by all rules and regulations set forth by applicable licensing and regulatory bodies, as well as UHC policies and procedures.

PERSONAL CONTACTS

The position requires contact with staff at all levels throughout the organization. There are also external organization relationships that may be a part of the work of this individual.

PHYSICAL EFFORT AND WORK ENVIRONMENT

• Must be physically able to sit, stand, and walk for long periods of time. Be able to bend, lift, and carry files from one location to another.
• Must have visual acuity and the ability to differentiate colors, and sustain long periods of computer usage.
• May sit for prolonged periods of time at a desk or in an automobile and/or may use the telephone for long periods of time.
• The office environment may be stressful with multiple, time-sensitive tasks to be accomplished within a short period of time.
• Must be able to work any time of the day, independently with minimal supervision, be capable of making sound business decisions, be detail oriented, alert, and self-motivated.
• Must be able to effectively manage difficult situations, staff, and customers.
• Refer to the attached ADA check list.

RISKS

The position involves everyday risk and discomforts, which require normal safety pre-cautions typical of such places as offices, meetings, training rooms, and other UHC health Care Sites. The work area is adequately lit, heated, and ventilated. All medical services shall be provided according to medically accepted community standards of care. The employee shall provide evidence of recent (within the past twelve (12) months) health assessment that includes a PPD and/or chest x-ray results.

The statements contained herein describe the scope of the responsibility and essential functions of this position, but should not be considered an all-inclusive listing of work requirements. Individuals may perform other duties as assigned including work in other areas to cover absences or relief to equalize peak work periods or otherwise balance the workload.