Care Coordinator - MHN

Responsibilities

• Maintains Medical Home Network (MHN) portal.
• Gathers and delivers required documents for care management model, such as medical records outside of CCHC, referral/consult notes, and post hospitalization records.
• Involves in the initial patient screening process, initial patient survey, reminder patient phone calls, and provides education under the guidance of the care team.
• Follows up with patients in the hospital/clinic setting as needed.
• Audits patients’ records.
• Serves as a trained health coach to patients (CCHC will provide motivational interviewing training).
• Serves as a liaison to multiple departments, agencies, and provider offices.
• Schedules appointments and monitors compliance with keeping appointments.
• Documents all correspondence in MHN portal and electronic medical records, as necessary.
• Collaborates with patient’s Medical Home to arrange conference calls as needed.
• Collaborates with the care management team to develop the patient’s individualized care plan.
• Works with care team to improve identified outcomes by using MHN quality measures.
• Works with care team to identify extrinsic barriers to adherence (i.e., transportation, financial concerns or pharmacy) and works with patient and team to alleviate barriers.

Qualifications

• High school diploma or equivalent required.
• No licensure required.
• At least three years of experience in a medical office; experience working in an ambulatory environment required.
• One to three years of experience with electronic medical records.
• Medical Assistant program completion preferred.
• Knowledge of the needs of highly complex patients.
• Strong verbal and written communication skills and interpersonal skills.
• Good organizational skills.
• Ability to multi-task and be self-motivated.
• Ability to work effectively independently and as part of a team.
• Bilingual highly desirable.