Clinical Care Coordinator RPM

Essen Medical Associates•Bronx, NY

About The Position

Overview At Essen Health Care, we care for that! As the largest privately held multispecialty medical group in the Bronx, we provide high-quality, compassionate, and accessible medical care to some of the most vulnerable and under-served residents of New York State. Guided by a Population Health model of care, Essen has five integrated clinical divisions offering urgent care, primary care, and specialty services, as well as nursing home staffing and care management. Founded in 1999, our over 20-year commitment has fueled an unwavering dedication toward innovating a better healthcare delivery system. Essen has expanded from a single primary care office to an umbrella organization offering specialties from women’s health to endocrinology, from psychiatry to a vast array of other specialties. All clinical services are offered via telehealth or in-person at over 35 medical offices and at home through the Essen House Calls program. Essen Health Care is the place Where Care Comes Together! We are looking for the most talented and effective individuals to join our rapidly growing company. With over 1,100 employees and 400+ Practitioners, we care for over 250,000 patients annually in New York City and beyond. From medical providers to administration & operational staff, there is a career here for you. Join our team today! Job Summary Job Summary: The Clinical Care Coordinator (CCC) works in collaboration with the primary care provider and all other members of the care team to support chronic disease care management for high-risk, high-need patients in a manner that is medically appropriate and cost effective. As a patient advocate, the CCC is responsible for direct and indirect patient care, helps identify clinical and health-related social needs and connects patients with relevant community resources.

Requirements

Proficiency in both English and Spanish (additional languages a plus)
Medical Degree (International or National)
Successfully completed Essen Medical Clinical training
The ability to work independently and exercise clinical judgment in interactions with providers, patients, and their families/caregivers
Good bedside / telephone-side manner
Good communication and computer skills, and cooperative attitude

Responsibilities

Conduct primarily telephonic communication with patients to support the provider in addressing patients’ medical and social needs.
Occasionally patients in their homes to support proactive and efficient care delivery.
Serve as the contact, advocate, and informational resource for patients, care team, family/caregiver(s) and community resources.
Facilitate patient access to appropriate medical and specialty providers.
Educate and refer patients to community resources.
Develop a comprehensive, collaborative care plan, based on provider treatment plan, evidence-based chronic care guidelines, and patient/family goals for patients to promote adherence to provider recommendations and instructions.
Assist with and facilitate the transition of care from inpatient settings such as hospital, rehabilitation facilities and skilled nursing facilities to home.
Address medication adherence.
Complete daily tasks such as taking clinical notes, reviewing medical records, following up on care gaps, coordinating chronic disease care, and other duties as assigned.
Provide education to patients, families/caregivers regarding resources for health care management, and condition exacerbations.
Communicate changes in patient’s status timely with the care team.
Work with the Administrative staff to provide feedback that can assist in identifying and improving day-to-day operational processes.