Clinical Care Coordinator / Must be IMG! - The Bronx, NY

Job Description

Job Description

Position Title : Clinical Care Coordinator – House Calls – ACO REACH / VBP Team

Position Summary : The Clinical Care Coordinator works in collaboration with the primary care provider and all members of the care team. Develops care initiatives to assess and coordinate chronic disease care management for their patient population in a manner that is medically appropriate and cost effective. Responsible and accountable for direct and indirect patient care for designated patient populations. Assesses healthcare needs and identifies community resources. Serves as patient advocate and assists in identification and improvement of service delivery.

Essential Functions :

o   Collaborate in overseeing patient’s clinical and social care.

o   Conduct face-to-face assessments for all patients to assess their medical and social needs twice a week

o   Schedule appointments and transportation

o   Take hotline calls and serve as the contact point, advocate, and informational resource for patients, care team, family / caregiver(s) and community resources

o   Facilitate patient access to appropriate medical and specialty providers

o   Educate and refer patient to community resources

o   Develop a comprehensive, collaborative care plan, based on provider treatment plan, evidence-based chronic care guidelines, and patient / family goals for patients in the chronic disease registries, recent discharges, and those in care transition to promote adherence to provider recommendations and instructions.

o   Assist with and facilitate the transition of care from inpatient settings such as hospital, rehabilitation facilities and skilled nursing facilities to home.

o   High risk and chronic disease management including :

o   Provide care via face-to-face, telephonic and / or electronic communication.

o   Provide individual patient / family education and self-management support that is appropriate based on language, cognitive abilities, literacy level, learning style, cultural norms, patient preference, readiness for change and resources available.

o   Address medication adherence.

o   Provide education to patients regarding health conditions.

o   Collaborate in goal planning and care management.

o   Communicate changes in patient’s status appropriately with the care team.

o   Perform all follow-up requests, with patient when appropriate.

o   Identify barriers when treatment goals are not met, treatment plan is not being followed or important appointments are missed.

o   Collaborate in developing patient treatment goals.

o   Identify patients who are overdue for visits, labs and referrals, contact patients and arrange for follow-up services.

o   Assist the patient in improved healthcare access and promote patient knowledge of health and behavior change.

o   Facilitate the initiation of diagnostic services, treatment planning and therapeutic treatment.

o       Utilize appropriate protocols and standing orders in delivering patient care.

o      Report quality measures.

o     Serve as a clinical and social needs resource and community referral resource.

o     Assist providers during home visits.

o      Participate in regular team meetings, huddles, staff meetings and quality improvement projects to improve patient care.

o      Consult staff to eliminate barriers to the efficient delivery of care. Identify service delivery problems and potential for effective patient management intervention.

• Perform all other duties as assigned.

Competencies :

Education and Experience :

o     Medical Graduation (International or National) Passed portions of the United States Medical Licensing Examination (USMLE)

o     Educational Commission for Foreign Medical Graduate (ECFMG)

o     Computer savvy – Word, Excel, PowerPoint, Adobe

o     Bilingual Spanish strongly preferred