Care Coordinator - Quality Improvement

Position Title: Quality Improvement Care Coordinator

Department: Clinical/Quality Improvement

Reports to: Care Coordination Manager

Purpose of Position:

The QI Care Coordinator works as part of the clinical team and is responsible to provide nursing care and related assistance to patients and families. The coordinator will act as a member of the care team and work in collaboration with health team members and is responsible for assisting in the promotion of the health and well-being of a panel of patients. The QI Care Coordinator is involved in indirect patient care and will function as a patient advocate in the team-based model of care. This position will help to develop and maintain positive relationships with patients by providing ongoing support for the patient and family. The QI Care Coordinator is responsible for developing, establishing and maintaining multiple working relationships with providers, medical assistants, nurses, front office staff and the Quality Improvement Department to ensure optimal quality health care. The QI Care Coordinator will provide clinical care management which includes pre-planning and follow-up care for patients.

Characteristics/Skills:

1. Interpersonal skills:

• Ability to work collaboratively and effectively communicate with patients and staff from diverse socio-economic backgrounds.
• Ability to build relationships with different types of people, including patients, members of the health care team as well as members of external organizations.
• Must have a friendly, compassionate, and patient-centered approach and provide stellar customer service in all situations.
• Acts as a member of the care team, working in collaboration with the clinical and non-clinical staff to promote the health and wellbeing of the patients.
• Strong communication skills to relate to patients/families, and other health care team members.
• Treating all patients with dignity and compassion without creating barriers.
• Must be an excellent problem solver and skilled in conflict resolution.
• Possess leadership qualities.
• Ability to adapt to changing environment.
• Self-motivated and self-directed to work independently as well as the ability to engage with various teams across the organization.
• Maintain professionalism and promote Carevide in a positive manner in the community.
• Commitment to Carevide’s mission and vision.
• Commitment to the mission of care coordination.

1. Organizational skills:

• Ability to manage multiple priorities and remain highly efficient without sacrificing personalized patient care.
• Ability to conduct appointment tracking, closed loop tracking for ordered services, patient follow up and other coordination tasks in an efficient and timely manner.
• Excellent time management skills and ability to meet goals and deadlines.

1. Clinical skills:

• Excellent clinical skills
• Maintain standards of care and patient safety
• Ability to read and understand reports, data and medical information
• Knowledge of and ability to educate on a variety of health care related topics.
• Ability to document clearly and professionally in the patient medical record using accurate medical terminology.

Essential Functions:

Functions and job duties may vary somewhat from site to site. QI Care coordinators may temporarily perform other duties as assigned to maintain operations and services.

1. Conducts patient needs assessments and reassessment services.
2. Assists with patient navigation for needed services when indicated by needs assessments for services such as specialist referrals, mental health, housing, crisis, food insecurity, etc. to help the patient understand the steps to receive appropriate medical care and reduce barriers to receiving care.
3. Works to close the loop on treatment plans, diagnostic imaging, referrals and lab test.
4. Follows Standing Delegation Orders and organizational procedures to close as many patient care gaps.
5. Provides patient education on disease processes, self-management activities, importance of a medical home including continuity of care and regular medical care.
6. Employs knowledge of evidence-based guidelines to effectively communicate the importance of recommended procedures and testing.
7. Conducts patient follow up outreach activities as indicated for uncontrolled chronic illnesses, open care gaps, patients not recently seen by the center, and missed appointments of a significant nature.
8. Based on patient registries or other systems, track patients due for preventative care, chronic disease management, follow-up of abnormal results or other health care services to identify gaps.
9. Participates in on-site Staff Meetings and Care Team meetings in health centers to discuss client care needs, share information and facilitate a focus on improving delivery of care and improving patient outcomes with a compassionate and patient-centered approach.
10. Maintains open channels of communication between all appropriate providers, support staff, patients and the quality improvement department.
11. Shares quality performance reports with health center staff to perpetuate improving patient health outcomes.
12. Maintain protocols/ care guidelines in patients EHR chart.
13. Obtains records for specialist appointments and hospital follow-ups when a transition of care is identified.
14. Initiate outreach and missed appointment procedures as indicated.
15. Employee will participate in ongoing training activities as provided by the organization related to assigned tasks and providing patient-centered care.

Evaluation:

Evaluations of work performance will be on-going, and will be carried out by the Care Coordination Manager, and will include specific duties and responsibilities of this position description along with employee professionalism and general working behavior. Formal evaluations will normally be performed annually, but may be initiated at other times by the Care Coordinator Manager.

General Qualifications and requirements:

1. Completed an accredited Medical Assistant program.
2. 1 year of experience in Family Medicine preferred.
3. Experience with administrative duties.
4. Basic Life Support certification
5. Computer literacy required with knowledge of Microsoft Word, Excel and PowerPoint.
6. Appropriate home internet capabilities to support remote work if necessary.
7. Bilingual (English/Spanish) required.