Care Coordinator bei None

 Position Title: Care Coordinator

Supervisor: Chief Clinical Officer

Department: Compass Community Health

Work Location: 11th Street Clinic

Supervises: Not Applicable

Date Effective: February 2023, Rev. 3/2025, Rev. 10/2025

FLSA Status: Non-Exempt

POSITION SUMMARY:

The Care Coordinator coordinates team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. Facilitates a “shared goal model” within and across settings to achieve coordinated high-quality care that is patient and family centered.

ESSENTIAL FUNCTIONS:

Essential functions are duties, which are essential or primary to the position or the reason the position exists. An individual must be able to perform the essential functions of the position with or without reasonable accommodation.

1. Provides a coordinated, strategic approach to detect early and manage the chronically ill patient population. 
2. Assists in coordinating high risk patient care, including patients with co-morbidities or at risk for readmission to a hospital setting.
3. Implement an effective internal tracking system for identified patients needing or receiving care coordination services. 
4. Participates in scheduled care team huddles to assist in pre-visit planning.
5. Coach patients and families toward behavior modification and successful self-management of their chronic disease. 
6. Facilitates health and disease patient education.
7. Facilitates patient access to appropriate medical and specialty providers.
8. Assists patients through the healthcare system by acting as an advocate.
9. Ensures effective tracking of test results, medication management, and adherence to follow-up appointments.
10. Coordinates continuity of patient care with patients and families following hospital or ER utilization and follow up from specialty providers.
11. Performs duties utilizing policy, protocols, and/or standing orders for delivering care and care coordination. 
12. Works with other health care center staff to maintain a clean, safe, and organized environment for staff and patients. 
13. Positively represents the department/agency through appropriate interaction, personal appearance, and attitude. 
14. Maintains patient confidentiality at all times as required by 42 CFR and HIPAA. Safeguard healthcare consumer privacy and confidentiality with respect to communication, documentation, and data.
15. Use electronic health record to retrieve relevant information and to document care concisely.
16. Consider clinical and cost-effectiveness in decision making about the organization and delivery of services.
17. Demonstrate understanding in use of IT resources and patient database.
18. Demonstrates understanding and importance of data collection and analysis and is able to work with internal IT resources on collection and reporting methods.
19. Demonstrates effective delegation skills to streamline operation workflows and optimize inter-office resources. 

SECONDARY FUNCTIONS:

Secondary functions are duties, which are not exclusive of the position, can be performed by other positions; however, secondary duties are to be performed for the efficiency of Compass Community Health.

1. Assists with office tasks as needed.
2. Performs any other duties as assigned Chief Clinical Officer.
3. Develop and sustain positive working relationships with patients, families, and providers. Explain to patients and family the roles and responsibilities of each team member and how they will work together to provide services.
4. Remain fluent in terminology pertaining to a healthcare setting.
5. Respect and respond to the leadership displayed by other providers in a healthcare setting or team.
6. Facilitate collaborative care by sharing relevant information with others through communications that are authorized by the patient and are permissible under HIPPA and related laws, regulations, and policies.
7. Assess the nature of the patient's family and social support system that have an impact on healthcare.
8. Ensure the flow and exchange of information among the patient, family members and linked providers.
9. Use wellness and recovery models in conceptualizing the health and healthcare of consumers.
10. Detect signs of abuse, neglect, domestic violence, and other trauma in patients.
11. Recognize the signs, symptoms and treatments of the most common health conditions and health crisis in a health care environment.
12. Understand the symptoms and treatments for the most common health conditions.
13. Ensure the flow and exchange of information among the healthcare consumers, family members and providers.
14. Support patients in considering and accessing complementary and alternative services designed to support health and wellness.
15. Provide information, education, guidance and support to family members and other caregivers.
16. Coordinate with health plans in identifying and addressing patient and population needs.
17. Promote patient and family adherence to healthcare plan.
18. Deliver support in addressing the consequences of illness or injury.
19. Plan and deliver services with an understanding of the healthcare needs of the population being served.
20. Establish and pursue individual and team-based improvement goals.
21. Participates in Patient Centered Medical Home team meetings and quality improvement activities.
22. Participates in data collection, review of respective outcomes reporting, as well as programmatic clinical audits and evaluation related to Patient Centered Medical Home initiatives and other quality programs as appropriate.

COMPETENCIES:

1. Knowledge/skill regarding patient/family health care practices across the life span.
2. Ability in the area of effective communication and interpersonal skills with public and co-workers.
3. Demonstrates appropriate understanding of working with confidential material and situations.
4. Ability to understand and assimilate new information quickly.
5. Ability to accurately complete reports, gather statistics, transfer data.

MINIMUM QUALIFICATIONS. INCLUDING TRAINING AND EXPERIENCE:

1. Holds and maintains an active medically related licensure (LPN, MA, etc.) preferred.
2. Prior experience working in patient/family health care environment preferred.
3. Previous experience in caring for chronic disease patients preferred.
4. Proficient in communication technologies.
5. Previous experience with electronic record and health IT systems.
6. Previous experience working with a variety of populations. Effective organizational skills and ability to collect and maintain data required. 
7. Can multi-task and work well in fast paced setting. 
8. Maintains applicable agency training.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to communicate effectively; use hands and fingers to handle or operate tools, equipment, or controls; and to reach, bend, and lift as necessary. The employee may be required to stand or sit for extended periods and occasionally move or lift up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, and the ability to adjust focus.