MEDICAL CARE COORDINATOR bei Memorial Regional Health

 ESSENTIAL FUNCTIONS AND BASIC DUTIES:                                                                                                             

Supervisory-Specific Performance Expectations, Duties, and Responsibilities:

• N/A

Position-Specific Performance Expectations, Duties, and Responsibilities:

• Transition Care Management (TCM). Outreach to patients within 2 business days of being discharged from a hospital admission to provide medication reconciliation, discharge instructions review, and confirm a follow-up appointment has been scheduled or assist in scheduling a follow-up appointment with a Primary Care Physician. Complete monthly outreach to provide ongoing support; complete documentation for coding and billing in a timely manner.
• Chronic Care Management (CCM). Enroll eligible patients in CCM services; work with patients, family/caregivers, and Family Practice Providers to develop individualized care plans; monitor progress to reduce health decline and prevent unnecessary hospitalizations. Support patients in setting and achieving self-management goals through regular check-ins, education, and encouragement, addressing physical, mental, social, and environmental factors that impact health. Complete monthly outreach to provide ongoing support; complete documentation for coding and billing in a timely manner.
• Patient Navigation (PN): Provide patient navigation assistance to patients with newly diagnosed or undetermined conditions in setting-up appointments with specialists, health education related to their condition(s), monitoring and communication of test results, connecting patients to appropriate services, working with other departments and/or organizations to ensure completion of prior-authorizations and other insurance concerns, and overcoming other barriers to care.
• Value-based Care (VBC). Support data-driven VBC initiatives for Medicare, Medicare Advantage, Medicaid, and commercial insurance plan beneficiaries. Includes direct patient outreach for medication adherence; and collaboration with Primary Care Physicians (PCP) and clinic staff to monitor and follow-up with high-risk and impactable patients identified through claims data as needing wellness visits, follow-up appointments, lab work, and other care.
• • Identify and address barriers to care, including social needs such as housing, transportation, safety, and income, connecting patients with appropriate MRH and community-based resources in collaboration with MRH’s Social Need Care Coordinators.
  • Facilitate communication and coordination among MRH departments, external providers, third-party payers, and community agencies to support smooth patient navigation and continuity of care.
  • Document patient interactions, referrals, and after-visit summaries accurately in the electronic health record, ensuring appropriate coding and supporting reimbursement processes.
  • Identify at-risk patients for concerns like abuse, depression, or falls and follow established procedures for intervention and reporting.
  • Estimated time allocation: TCM 20%; CCM 50%; VBC 10%; PN 20%.

   

  General Requirements

  • Maintain accurate documentation of patient encounters and ensure timely reporting according to department and organizational standards and requirements.
  • Attend recurring staff meetings and trainings as assigned.
  • Participate in the development of processes to achieve improved health outcomes and programmatic efficiencies.
  • Meet patients onsite at the clinic/hospital, public spaces, homes, or other appropriate locations to assess needs and provide support.
  • Professional demeanor and ability to effectively communicate with patient, community members, professional partners, grantors, and in other professional settings.
  • Possess critical thinking and problem-solving skills, use data to make informed decisions, be both self-directed as well as a collaborative team member.
  • Occasional weekend work, and other duties as assigned.

   

  Organization-Specific Performance Expectations, Duties, and Responsibilities:

  • Demonstrates 100% commitment to performance in accordance with the CHOICE values of MRH and representing the organization in a positive and professional
  • Establishes and maintains effective verbal and written communication and good working relationships with all patients, staff, and
  • Adheres to MRH attire/dress code per policies and
  • Utilizes initiative; strives to maintain a steady level of productivity; self-motivated; and manages activity and
  • Completes annual education, training, in-service, and licensure/certification requirements; and attends departmental and organizational staff meetings or reads meeting
  • Maintains patient confidentiality at all
  • Reports to work on time as scheduled; completes work within designated
  • Actively participates in departmental and organizational performance improvement and continuous quality improvement
  • Strives to uphold regulatory requirements to ensure continual compliance with departmental, hospital, state, and federal regulations and
  • Follows policies and procedures for infection control, safety, and risk management to ensure a safe environment for patients, the public, and
  • Demonstrated success working in an integrated environment and working within a cross-functional team.

   

•  QUALIFICATIONS:                                                                                                             

  Minimum Requirements:

  • Must be at least 16 years of age (21 for driving positions with a valid driver’s license).
  • • Must be able to legally work in the United
    • Must be able to pass a background
    • Must be able to pass a drug screen and breath alcohol test (if applicable).
    • Must complete employee health

     

    Required Education/Licensure/Certification:

    • Unencumbered Registered Nurse (RN) licensure in the State of Colorado, or Bachelor of Science in Nursing (BSN), or equivalent licensure or degree, required.
    • Patient Navigation Certificate of Completion through the Patient Navigator Training Collaborative, Care Coordination Fundamentals through HealthTech, or equivalent training within six months of
    • Current BLS certification (or must be obtained within 90 days).

     

    Experience:

    • Minimum two years’ primary care, home health, or similar experience
    • Minimum two years’ experience working with geriatric and high-risk populations preferred
    • Experience with medical insurance, billing, and coding preferred
    • Fluent / conversational in Spanish preferred

     

    Skills/Abilities:

    • Apply National Patient Safety goals to care and
    • Work within a Healthcare Electronic Medical Record to chart and review patient data, and run reports. Communicate effectively, both in writing and
    • Establish and maintain effective working relationships with employees at all levels throughout the institution.
    • Interpret, adapt, and apply guidelines and
    • Identify and resolve problems in a proactive, collaborative
    • Commitment and leadership in regard to advancing diversity and
    • Initiative and self-motivation; strive to maintain steady level of productivity and good time
    • Strong analytical and critical thinking skills; attention to detail and
    • Outstanding customer service
    • Experience using MS Word, Excel, and

• Position Classification:  Non-Exempt

  Compensation Range: $33.58 TO $50.38

  Benefits:  Medical, Dental, Life, Retirement, Paid Time Off