Patient Care Coordinator (Temporary) - MA Certificate Required

Neighborhood Healthcare•Riverside, CA

11d

About The Position

The Patient Care Coordinator (PCC) supports Neighborhood Healthcare’s mission and vision by working with Primary Care Practice teams to improve patient health outcomes. The role primarily coordinates and provides panel management services for patients at highest risk of health deterioration, helping them achieve self-care goals by increasing access to health services and resources. This is a temporary, full-time position with an anticipated assignment end in April 2027. The PCC uses a primary care medical home model to coordinate team care, support preventive and chronic-care follow-up, engage patients and families, and help improve population management and patient care outcomes. The position also supports clinic productivity, quality improvement, and compliance with safety, infection control, privacy, and corporate integrity requirements.

Requirements

High school diploma or GED.
Medical Assistant Certificate or Diploma from an accredited program.
Current Basic Life Support (BLS) certification upon hire, maintained as a condition of employment; courses must follow AHA guidelines or equivalent recognized BLS standards.
Excellent verbal and written communication skills, including composition, typing, and proofreading.
Ability to interpret written, oral, diagram, or schedule-form instructions.
Knowledge of and experience with medical home health.
Ability to adapt to changing patient or organizational priorities.
Ability to manage multiple tasks simultaneously.
Critical thinking, decision-making, and problem-solving abilities.
Strong planning and organizational ability.
Ability to work both as part of a team and independently.
Ability to handle highly confidential information professionally and ethically.
Ability to lift or carry 20 pounds and stand for long periods.

Nice To Haves

One year of medical assistant experience within medical home health.
Experience in a nonprofit community health clinic.
Bilingual English/Spanish skills.

Responsibilities

Provide coordinated team care using the primary care medical home model to address current diseases.
Conduct panel management for preventive and health-maintenance follow-ups for as many patients as possible each day.
Contact new patients to welcome them, explain the medical home, and answer questions.
Schedule patients with chronic conditions for follow-up appointments according to preventive and maintenance-care schedules.
Perform population management tasks, including appointment scheduling, recalls, web portal callbacks, and telephone-encounter follow-up.
Call patients who miss appointments based on preventive and chronic-disease guidelines.
Delegate ECW telephone encounters and web portal messages to medical assistants and providers.
Improve productivity by arranging PCP follow-up visits, anticipating same-day appointment openings, and proactively keeping provider schedules full.
Track assigned tasks and logged PCP discussion topics, and report progress during weekly supervisor meetings.
Collaborate with and support the PCP in identifying and implementing improvements to population management and patient care outcomes.
Organize weekly pre-clinic team huddles to update progress toward goals, including Meaningful Use compliance and C.A.R.E. Transformation.
Coordinate monthly medical assistant team meetings to discuss progress toward PCMH goals and areas needing improvement.
Conduct and document patient end-of-visit interviews, coaching, and patient engagement conversations.
Reinforce information provided to patients and families with handouts to improve self-management skills and communication.
Educate patients during medical appointments as needed.
Serve as a first point of contact for patients and families with questions or concerns through the patient web portal and by phone.
Submit prior authorizations for medications, DME supplies, and other items as needed.
Support patient experience through courteous and helpful behavior, accuracy, and the values of Transforming Care.
Share accountability for patient health outcomes by coordinating with the PCP.
Complete ECW notes for care coordination and other services in a timely manner.
Prioritize activities according to need and required follow-up.
Provide accurate and timely reports to the supervisor as required.
Participate in quality improvement activities.
Help instill confidence in the organization’s care and facilities among patients, employees, and other stakeholders.
Assist medical assistants and patients as needed.
Follow safety procedures in the Illness and Injury Prevention Plan; promptly report injuries and unsafe conditions; use appropriate body mechanics; know the location of fire extinguishers and emergency exits; and follow infection-control and blood-borne pathogen protocols.
Protect patient, employee, and volunteer privacy and access information only on a need-to-know basis for business purposes.
Comply with corporate integrity and security regulations and report unethical, fraudulent, or unlawful behavior or activity.