Care Coordinator - ECM

SAC Health • San Bernardino, CA

1d • $25 - $29 • Onsite

About The Position

The Care Coordinator, ECM manages cases regarding utilization review, discharge planning, and patient services coordination. Collaborates with insurers, managed care organizations, referral providers, patients, and families to assist in developing case management guidelines. This role performs intensive case management for a caseload of low to moderate risk patients with chronic medical, behavioral, or substance use health conditions. The Care Coordinator will collaborate with patients and the care team to build integrated plans of care to address medical, behavioral, and social support needs, ensuring patient engagement meets program expectations and comprehensive, coordinated care. They will participate in Systematic Case Reviews, presenting patient needs in a prioritized and organized manner and assisting in developing a plan of care based on integrated feedback. The role involves compiling and analyzing patient/team data for prioritization and feedback to management, overseeing patient/team databases for accuracy, and actively monitoring results to ensure appropriate follow-up and diagnostic studies. The Care Coordinator will assist patients in following through on their care plan wellness goals via phone and in-person contact, and assist patients discharged from higher levels of care with transitioning to home, which may include medication reviews, referral follow-up, and linkage to external services. They will perform transition of care assessments and collaborate with the care team for successful transitions. Working within a team of nurses, behavioral health clinicians, and patient navigators, the Care Coordinator will ensure patient health needs are met by engaging patients, building rapport, and establishing trusting relationships. Active collaboration with the care team and extended network of care providers is essential, requiring effective communication across the healthcare continuum. The role also involves engaging and enrolling new patients into the program through outreach, ensuring team caseloads meet programmatic expectations, understanding program eligibility, and assisting patients in maintaining eligibility. Meeting value-based measurement expectations through data-driven, measurement-based care and utilizing reports to prioritize daily work are key aspects of the position. Home and/or community-based visits may be required, necessitating a reliable vehicle, valid driver's license, and auto insurance. Attendance at staff meetings, in-services, staff development, educational courses, workshops, and conferences is also expected, along with performing other duties as outlined in the official job description.

Requirements

• High School Diploma or GED required.
• Graduation from a Certified Medical Assistant Program is required.
• Medical Assistant Diploma/Certificate and Current CPR/BLS certification (must be American Heart Association or Red Cross accredited program).
• Valid California driver's license, and auto insurance is required.
• Must receive EPIC certification for the module you have been hired into.
• 2+ years as a Medical Assistant or related field required.
• Must be proficient in MS Office Suite (Word, Excel, PowerPoint, Outlook).
• Must be able to use widely support internet browsers.
• Must have the ability to use variations of electronic health records and other various databases.
• Must have excellent communications skills both orally and in writing.
• Must possess the ability to communicate with and relate to a diverse group of people including patients, community, and other staff.
• Must have strong conflict and problem resolutions skills.
• Must be flexible to perform a variety of tasks.
• Must be well organized and a self-starter.
• Must have strong analytical and problem-solving skills.
• Must be legally authorized to work in the United States on a full-time basis.
• Must not now or in the future require sponsorship for employment visas.

Nice To Haves

• Associate degree preferred.

Responsibilities

• Performs intensive case management for a caseload of low to moderate risk patients with chronic medical, behavioral, or substance use health conditions.
• Collaborate with patients and the care team to build integrated plans of care to address medical, behavioral, and social support needs.
• Participate in Systematic Case Reviews.
• Compile and analyze patient data/team data to provide prioritization and informed feedback to management.
• Actively monitor results to ensure appropriate follow-up and diagnostic studies are ordered and completed, as appropriate.
• Assist patients in following through on their care plan wellness goals, using both phone and in-person contact.
• Assist patients discharged from higher levels of care with transitioning to home.
• Perform transition of care assessments.
• Work within a team of nurses, behavioral health clinicians, and patient navigators to ensure patient health needs are met.
• Maintain active collaboration with the care team and extended network of care providers.
• Engage and enroll new patients into the program through in-person or telephonic outreach.
• Work with team members to ensure team caseloads meet programmatic expectations.
• Meet value-based measurement expectations through data-driven, measurement-based care.
• Home and/or community-based visits may be required based on patient and team needs.
• Attend and participate in staff meetings, in-services, staff development, educational courses, workshops, and conferences.
• Other duties as outlined in the official job description.

Benefits

• Industry Leading PTO Accrual (accrued per pay period)
• Sick Leave
• Paid Holidays
• Paid Jury Duty, Bereavement
• SAC Health Covers approximately 85% of Team Member health premium costs (may vary w/benefit plan selection)
• Retirement - up to 8% employer contribution
• Continuing Education and Learning Benefits
• Annual Mission Trip

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED