Salary: $0.00 to $1.00 /hour
The Patient-Centered Medical Home (PCMH) Care Coordinator will ensure the overall success of MHC’s PCMH program by collaboratively working with patients, physicians, practice teams and the health plan, to integrate the key features of the medical home. The focus of the PCMH Care Coordinator is to ensure the organization maintains care coordination as a patient and family centered, team-based, function that is designed to assess and meet the needs of patients. The Care Coordinator will work closely with the patient regarding the patient’s care to navigate effectively and efficiently through the health care system. The Care Coordinator will work collaboratively with Providers to determine additional care that may include referral to a specialist and responsibility to manage the relationship among all health care professionals (doctors, nurses, social workers, care managers, supporting staff, etc.). Care coordination includes addressing potential gaps in meeting patients’ interrelated medical, social, developmental, behavioral, educational, informal support system, and financial needs, in order to achieve optimal health and wellness, according to patient preferences.
v Promotes clear verbal communication amongst patients, care team, ensuring awareness regarding patient care plans.
v Responsible for carrying out key functions related to the success of the PCMH program including member outreach, PCMH reporting, performance measurement, acting as key liaison for PCMH overall activities (i.e. THCII, NCQA PCMH) and ensuring compliance is maintained via HRSA, Joint Commission, NCQA and other applicable agencies.
v Responsible for population health management (e.g. using data for population management to address chronic & acute care services), care management support (e.g. identifying high-risk patients for care management & care plan with self-care support recommendation and working collaboratively with the care team), and assisting with care coordination and care transition (e.g. referral tracking and follow-up and coordination care transition).
v Identify, assess, and prioritize individual patient needs and build rapport and trust with patient.
v Assist with review of performance measurement and quality improvement, which includes measuring and tracking patient performance on quality and efficiency measures, review and assess the member’s available data, including clinical/claims history, outpatient treatments, inpatient reviews, or other information, to assist in the monitoring and facilitation of adherence to prescribed care plans.
v Utilize the Care Coordination Tool (CCT) daily which provides several functionalities to calculate members’ risk scores and stratifies a providers’ panel for more focused outreach; generate reports and records closure of gaps in care; and identify hospital and ED admission, discharge and patient transfer information.
v Collaborates with the care team member regarding opportunities for optimizing care which includes working relationship with Providers to manually close gaps in care in the CCT system.
v Facilitates members understanding of the physician’s treatment plan, including but not limited to, prescription, refills, medical supplies, referral authorization of services, and when to seek care.
v Interviews the member and/or family to further assess social, emotional, functional and physical health status.
v Supports the transition of care outreach by ensuring follow up for patients following admission discharge or ER visit to ensure care transition is coordinate during patient care that shifts from being provided in one setting of care to another setting with the provider.
v Knowledge and understanding the core quality metrics for the PCMH program, HEDIS, and HRSA UDS.
v LPN with an active license in the state of TN.
v Minimum of 3 years of varied clinical experience required.
v Preferred 3 – 5 years of experience in direct patient care in a clinical setting.
v Minimum of 1-2 years of computer skills (Microsoft Office: Excel, Word) and medical software (Athena).
v Proficiency with Motivational Interviewing and/or other behavioral change techniques.
v Ability to build rapport and engage members in effective dialogue related to their treatment plan.
v Exceptional level of critical thinking, analytical and creative problem-solving skills required.
v Excellent oral and written communication skills, with problem-solving abilities.
v Exceptional interpersonal communication skills are required.