Care Coordinator II

About the role

The Care Coordinator II (CCII) plays a crucial role in onboarding and supporting the patient, including managing and coordinating their care plan. The CCII acts as a liaison between the patient or caregiver, primary care team, and external partners to ensure seamless communication and timely access to care.

Responsibilities

• Actively support an assigned panel of patients by providing timely complex care coordination for patients with physical and behavioral health care needs.
• Educate patients/caregivers on the services provided by Housecall Providers Primary Care.
• Escalate concerns to primary care team according to protocols.
• De-escalate high stress situations and complaints received and forwards to primary care team/leadership as appropriate.
• Cook up referrals for supportive services, labs, diagnostics or other coordination of care needs as requested by the primary care team based on insurance, location, patient preference, and order type.
• Schedule patient visits for assigned panel of patients based on urgency, geographic location, appointment type, provider availability and frequency of visit standards.
• Authorize prescription refills for non-controlled drugs if approved by clinician.
• Provide pharmacy support including verbal orders, when appropriate, to expedite or clarify medication fulfillment.
• Provide primary care coordination support to assigned panel of patients with physical and behavioral health care coordination needs.
• Review, process and approve incoming referrals; ensure all intake documentation is complete and clinically relevant.
• Absorb service appropriateness using medical terminology and clinical guidelines; collaborate with clinicians/supervisors for complex cases or exceptions.
• Manage DME orders, ensuring charting and all documentation requirements are met.
• Coordinate complex care with support services and community partners, including but not limited to home health, hospices, according to the patients’ plan of care.
• Coordinate with the care team to ensure consideration is given to unique needs in integrated planning and that physical and behavioral health care plans are timely and effective.
• Develop working partnerships with patient, family, caregiver and community care providers, payors regarding patient needs and care plans.
• Aid patients, caregivers and families in establishing/engaging with providers by coordinating appointment and transportation, as needed.
• Arrange family and/or caregiver attendance at appointments, and interpreters as required.
• Provide information about appointments, care plans, medications, referrals, prior authorizations, DME requests.
• Identify risk factors and service needs that may impact patient outcomes and address appropriately.
• Utilize a trauma-informed approach to provide patient-centric physical and behavioral health care and support including a person-centered approach to communication, education, and care planning.
• Assist patients with moving through the continuum of care based on clinical/medical/behavioral health needs by collaborating with the PCP, Primary Care Clinical Team (PCT), palliative care and hospice teams.
• Coach patients toward improved physical and behavioral health care behaviors and self-management.
• Cook up clinicians' diagnostic and lab orders, including lab and diagnostic testing, medical supplies and equipment.
• Provide timely outreach providing education, follow up on labs or diagnostics or clinical instructions from a member of the primary care team.
• Implement physical and behavioral health care coordination plan in collaboration with the patient’s care team, including patient, family, caregiver, internal team members, as well as external providers, case workers and other relevant parties.

Qualifications

• Minimum 4 years of experience in a healthcare setting, including experience with medical records system.
• Preferred Experience in a primary care clinic, home health, or hospice setting.
• Minimum 1 year of experience in customer service.
• Knowledge, Skills And Abilities Required:
  • Advanced knowledge of healthcare language, including medical and/or behavioral health terminology, basic patient care and community resources.
  • Advanced knowledge of barriers to care such as language, cultural factors, transportation, ability to self-manage and psychosocial issues and bring those to the attention for the care team.
  • Knowledge of HIPAA privacy rules and regulations.
  • Advanced knowledge of basic conflict management and de-escalation techniques.
  • Leadership skills, including the ability to organize work and train/mentor others.
  • Participate in work-related continuing education when offered or directed.
  • Excellent customer service skills, including the ability to interact professionally, patiently and courteously with staff, patients, families and vendors over the phone and in-person.
  • Motivational interviewing, healthcare teaching and coaching skills or has the ability to learn.
  • Advanced organizational skills, plus the ability to manage multiple tasks and timelines in a high-stress environment.
  • Prioritize tasks, manage telephone calls with a professional demeanor, problem solve and stay focused.
  • Work independently and collaboratively.
  • Use good judgment, personal initiative and discretion to perform job responsibilities.
  • Ability to take initiative and utilize innovative techniques and ingenuity.
  • Advanced ability to establish and maintain effective communication and collaborative relationships with colleagues, departments throughout Housecall Providers and CareOregon, as well as external providers and community agencies.
  • Advanced Computer application skills, including MS Windows, Word, Excel and Outlook.
  • Detailed understanding of electronic medical record systems and the ability to integrate updates to those workflows on a regular basis.
  • Advanced ability to facilitate group discussion or case review.
  • Learn, focus, understand and evaluate information and determine appropriate actions.
  • Employ critical thinking and draw conclusions from conversations and written or computer-generated material.
  • Communicate effectively with diverse staff and patients, their families and caregivers.
  • Work effectively with diverse individuals and groups.
  • Accept direction and feedback, as well as tolerate and manage stress.
  • See, read, and perform repetitive finger and wrist movement for at least 6 hours/day.
  • Hear and speak clearly for at least 3-6 hours/day.

Benefits

We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. Housecall Providers offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information. We are an equal opportunity employer Housecall Providers is an equal opportunity employer. The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.