Job Summary

The Care Coordinator is to coordinate team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. Facilitates a “shared goal model” within and across settings to achieve coordinated high-quality care that is patient and family centered.

Essential Functions

• Promote the mission, vision, and values of the organization
• Recognizes and responds to opportunities for improvement.
• Provides mentoring/coaching of other population health and care coordination team members and coach patients/families toward successful self-management of their chronic disease.
• Utilize tools and documents that support a guided care process, collaborate with patients/family toward an effective plan of care.
  • Create connections between vulnerable populations and the health care system by assessing patient and family’s unmet health and social needs
  • Care coordination and care transitions for clients in the form of developing a care plan based on mutual goals with patient, family, and provider’s emergency plan, medical summary, and ongoing action plan, as appropriate
  • Monitor patient’s adherence to plan of care and progress toward goals in a timely fashion, facilitate changes as needed
  • Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time
  • Assist clients with enrollment in programs and benefits for which they are eligible
  • Encourage cultural competence among health care professionals serving vulnerable populations
  • Advocate for vulnerable populations within the health care system and the community at large
  • Build capacity within the clinic and the community at large to address health issues
  • Provide effect communication to improve health literacy.
• Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g. Diabetes Educator)
• Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow up, and integration of information into the care plan regarding transitions-in-care and referrals
• Serve as a point of contact, advocate, and informational resource for patient, family, care team, payers, and community resources and facilitate and attend meetings between patient, families, care team, payers, and community resources, as needed
• Ensure effective tracking of test results, medication management, and adherence to follow-up appointments.
• Develop systems to prevent errors (e.g. effective medication reconciliation and shared medical records)
• Attend and actively participate in Care Coordinator related training and meeting activities (Health Coach certification, quarterly Regional Workshops, monthly cohort calls with NRACO Coordinators and Coach)
• Perform regular visits to provide patient and family support and education
• Collect data and write brief reports to meet evaluation needs of the program

Non-Essential Functions

• Perform other duties as assigned

Professional Requirements

• Adhere to dress code, appearance is neat and clean.
• Complete annual education requirements.
• Maintain patient confidentiality at all times.
• Report to work on time and as scheduled.
• Wear identification while on duty.
• Maintain regulatory requirements, including all state, federal and local regulations.
• Represent the organization in a positive and professional manner at all times.
• Comply with all organizational policies and standards regarding ethical business practices.
• Communicate the mission, ethics and goals of the organization.
• Participate in performance improvement and continuous quality improvement activities.
• Attend regular staff meetings and in-services.

Qualifications

• Level I:
  • One year of community-based experience providing advocacy and support which has included significant public contact OR Completion of a GED or high school diploma which has included public contact
• Level II
  • Current CHW Certification in New Mexico
• Level III
  • Licensed practical or registered nurse in New Mexico, preferred
• In addition to:

• Current Basic Life Support (BLS) certification or must be obtained within thirty (30) days of hire
• Current Advanced Cardiac Life Support (ACLS) certification or must be obtained within six (6) months of hire
• Pediatric Advanced Life Support (PALS) certification or must be obtained within six (6) months of hire
• 3-5 years’ experience in clinical or community health settings -preferred
• Previous experience in caring for chronic disease patients required.
• Previous Care Coordination, Case Management or Home Health experience-preferred
• Bilingual in English and Spanish preferred
• Experience with navigation of local medical and social support systems -preferred
• Previous experience with health systems and data reports-preferred

Knowledge, Skills, and Abilities

• Knowledge of community health services
• Strong organizational and demonstrates the ability to maintain accurate notes and records.
• Strong interpersonal skills
• Ability to demonstrate strong essential leadership, communication, education and collaboration and counseling skills.
• Ability to communicate proficiently through technology (email, cell phone, etc.)
• Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required.

• Ability to demonstrate continual learning skills, effects changes in approach to care based on established, evidence-based practice.

• Ability to determine appropriate course of action in more complex situations
• Ability to work independently, exercise creativity, be attentive to detail, and maintain a positive attitude
• Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work
• Ability to maintain confidentiality of all medical, financial, and legal information
• Ability to complete work assignments accurately and in a timely manner
• Ability to communicate effectively, both orally and in writing
• Ability to handle difficult situations involving patients, physicians, or others in a professional manner
• Knowledge of local health disparities and resources to address those disparities
• Requirements and procedures for care coordination, data management, and Electronic Health Records.
• Ability to conduct presentations on health and wellness activities and self-management of health concerns
• Ability to facilitate small groups to facilitate behavior change
• Basic understanding of health insurance programs such as NM Medicaid and MCO’s.

Physical Requirements and Environmental Conditions

• Working irregular hours including
• May require patient home visits as needed
• Physically demanding, high-stress environment
• Exposure to blood and body fluids, communicable diseases, chemicals, radiation, and repetitive motions
• Pushing and pulling heavy objects
• Full range of body motion including handling and lifting patients

• Position requires light to moderate work with 50 pounds maximum weight to lift and carry.
• Position requires reaching, bending, stooping, and handling objects with hands and/or fingers, talking and/or hearing, and seeing.