• Health Care Coordinator

    Regular Full-Time
    Medical Team
  • Overview

    Job Summary: This position is responsible for integrated patient care coordination under the direction of the Integrate Care Team model.


    Primary Job Responsibilities:

    • Optimized data to identify high risk patients and engage them in care
    • Administers and records data from applicable behavioral health and primary care health screens
    • Educates patient/family about diagnostic procedures, nutrition and maintenance of health and wellness.
    • Adheres to infection control/safety guidelines and confidentiality policies.
    • Participates in the development of the shared plan of care with other team members and safely coordinates the implementation of that plan.
    • Promotes wellness by providing disease management information, patient education materials, communicating physician advice/instructions.
    • Coordinates care of patients with internal and external professionals.
    • Coordinate the scheduling of integrated care appointments and procedures according to established protocol.
    • Maintains/reviews patient records, charts and other pertinent information.
    • Responds to/refers patient treatment-related phone calls.
    • Professionally represents A&C in the community and with medical practices including participating in public health fairs and events.
    • Documents and coordinates data, information, and clinical practices across multiple EMR’s and databases.
    • Coordinates and follows patient referrals to specialty provider to enable/encourage patient attendance and follow up return to clinic.
    • Coordinate clinical data exchange and retrieval of results with specialty providers
    • Coordinates discharge and transition planning for patient care.
    • Maintains patient confidentiality.
    • Performs complete assessment of medical and behavioral healthcare needs, family support structure, and patient eligibility status to obtain resources.
    • Identifies and addresses barriers including, but not limited to, physical limitations, transportation issues, financial constraints, and lack of support to manage healthcare needs.
    • Effectively communicates barriers to healthcare team
    • Knowledgeable of Medicaid/Medicare guidelines, Marketplace plans, and commercial insurance benefits and services.
    • Develops relationships with community partners to provide patients/clients access to resources such as free medications and reduced healthcare/dental services.
    • Advocates for patients/clients by communicating patient desired healthcare choices.
    • Facilitates care conferences between patient, family, and healthcare team to ensure plan of care goals are met.
    • Plans and coordinates a full continuum care such as nursing home placements, home healthcare setup, arranging infusion clinic services, etc.
    • Assesses medical necessity
    • Experienced with MCE plan benefits high preferred.
    • Perform other related duties as directed or required.


    Education: BSW or closely related degree.  Certified MA or LPN preferred, but not necessary.


    Experience: 3 years preferred.


    Performance Requirements:



    1. Knowledge of medical terminology and anatomy.
    2. Familiarity with population health and population management best practices.
    3. Familiarity with health care systems, regulations, policies, and functions. Understanding of documentation standards.
    4. Knowledge of care management processes and best practices.
    5. Knowledge of medications and their effects on patients.
    6. Knowledge of infectious disease management and control and safety standards.



    1. Skill in reading and following written and oral medical orders.
    2. Skill in initiating appropriate emergency procedures.
    3. Skill in handling a number of tasks simultaneously.
    4. Skill in prioritizing tasks.
    5. Skill in positive people interactions and patient engagement



    1. Ability to communicate effectively in person, by phone and in writing.
    2. Ability to establish and maintain effective working relationships with coworkers and diverse patient populations.
    3. Ability to perform mathematical calculations
    4. Ability to competently use Microsoft Office.


    Equipment Operated: Phone, computer, medical charts, EMR.


    Work Environment: Medical exam and treatment rooms and medical offices. Environmental setting (lighting, temperature, air quality, acoustics) controlled.


    Physical Requirements: Must possess the physical and mental abilities to perform the tasks normally associated with a Medical Care Manager such daily standing, squatting, walking, bending, and maneuvering. Occasional exposure to communicable diseases and biohazards. Stress can be triggered by workload and difficult patients.


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