Spanish Care Coordinator

Cabarrus Rowan Community Health Centers•Concord, NC

35d

About The Position

The Care Coordinator will assist patients in navigating the care among primary care, behavioral health, specialists, and other members of the integrated care team. The staff member will assist with appointment scheduling and follow-up, disease management, community resources, and patient advocacy. With input from the clinical team and data from the EMR, he/she will identify high risk or utilization patients for additional support and care plan development. The Care Coordination will also serve as additional clinical or clerical support for the facilitation of care transitions. Other duties may be assigned to suit the demands of patients, according to the respective location of the clinical site.

Requirements

Knowledgeable about major chronic conditions; including diabetes, obesity, and heart disease.
A basic understanding of major community resources in Cabarrus and Rowan counties; including medical specialists, transportation, and other support services.
Experience in collaborating with primary care, specialists, hospitals, home health, and other essential health agencies.
Strong skills in critical thinking and motivational interviewing.
Ability to support high risk and comorbidity patients.
Ability to interact and render service impartially to diverse populations.
An understanding of cultural competency, health literacy, and social determinants of health as it relates to promoting positive health outcomes.
Interacts with respect and in a professional manner with patients, staff and external customers.
Must be able to commute independently between CRCHC sites.
Knowledge of community resources; including social services, medical specialists, and other treatment programs.
Excellent leadership and coaching skills.
Strong computer skills with knowledge of Microsoft Office products.
Excellent verbal and written communication skills.
Able to work independently and in a multidisciplinary team.
Able to effectively utilize an electronic health record to document all patient encounters.

Nice To Haves

1 year in a generalized public health care setting preferred or 1 year of experience in care coordination, discharge planning, or health coaching preferred.
Associate degree in healthcare related field preferred.
Certified Nursing Assistant or Medical Assistant preferred

Responsibilities

Remains current on all Medicaid Managed Care benefits and eligibility requirements.
Delivers courteous and respectful communication with staff, peers, and patients.
Facilitate coordination of care for high-risk patients and/or targeted populations within a primary care setting
Assist clinical staff in conducting care transitions for patients leaving the hospitals, including the coordination of care with primary care, home health, outpatient clinics, and skilled nursing facilities with supervisory support.
Review electronic medical records and other reporting tools to identify at-risk patients.
Identify community resources to reduce barriers to care, such as transportation services.
Contact patients overdue for care and encourage appropriate follow up care.
Contacts patients for COVID-19 management follow-up in accordance with workflow and policy.
Participate in quality improvement activities by initiating or contributing to monitoring, measuring, analyzing, improving and/or controlling program goals, objectives and/or services.
Assists QI initiatives to include events and outreaches (as needed).
Assists with Panel management for patients looking to establish care.
Support current incentive, regulatory, and certification requirements (such as Meaningful Use, PCMH and UDS) through documentation, participation in initiatives, and other activities as directed.
Facilitates members understanding of the physician’s treatment plan, including but not limited to, prescription refills, medical supplies, referral authorization of services, and when to seek care with supervisory support.
Interviews the member and/or family to further assess social, emotional, functional, and physical health status.
Translation services will be expected upon request from management.
Other tasks as assigned