Clinical Care Coordinator (ACO- House Calls)

About the role

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.

Responsibilities

• Conduct telephonic and in-person communication with patients to support the provider in addressing patients’ medical and social needs.
• Occasionally visit patients in their homes to support proactive and efficient care delivery, and to evaluate patients signs, symptoms, and social needs.
• 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.

Requirements

• Standard Hours Per Week 40. Mostly in-person.

Qualifications

• Fluent in English and Spanish is a plus
• Some amount of experience in health care, preferably in care management or another patient-facing role
• A strong customer-service orientation, and extremely good verbal communication skills.

Skills

• The ability to work independently and exercise clinical judgment in interactions with providers, patients, and their families/caregivers
• The ability to function in a fast-paced environment, to be held accountable for high performance standards, and to hold others accountable for high performance
• Strong Familiarity with Electronic Health Records (EHR), able to review a medical chart for evidence of a disease

Benefits

• Essen Health care is proud to be an equal opportunity employer, and we seek candidates who desire to work in and serve an ethnically diverse population.

Pay

• Not specified

Schedule

• Not specified