Job Title: Site Clinical Coordinator

General Summary of Duties: Assist in the delivery of primary health care and patient care management. Assist with patient management in the transition out of hospital into the community. Perform a variety of tasks consistent within the scope of practice including, but not limited to, education, assessment, planning, evaluation, and care plan development.

Supervision Received: Reports to Practice Manager, Site Clinical Director, and Director, Population Health and Quality Improvement

Supervision Exercised: None

Typical Physical Demands: Requires manual and finger dexterity and eye-hand coordination. Position involves sitting for extended periods of time with brief periods of walking and standing. Requires corrected vision to normal range, 20/40 or better, and corrected hearing to normal range. Requires excellent customer service and the ability to multitask. May be exposed to communicable diseases and/or bodily fluids.

Typical Working Conditions: Frequent sitting with occasional standing and walking. Desk work with constant use of keyboard and computer programs (email, excel, word, and many internet-based programs/platforms). Frequent use of multi-line phone and office supplies and equipment such as fax machines, copy machines, and printers.

Primary Duties/Responsibilities (Include but not limited to):

1. Work closely with the site RN Care Manager to identify patients who would benefit from care management.

a. Steer patients to appropriate care management services based upon attribution within VBC programs.

i. MDPCP-AHEAD

ii. Medicaid-AHEAD

iii. Medicare FFS

iv. CareFirst-ACO

v. Aetna-ACO

vi. United-ACO

2. Navigate CRISP platforms (CEND Population Explorer) to identify hospital discharges and admissions for tracking and follow-up with patients within 2 business days of discharge from an inpatient setting and within 1 week of discharge from an ED visit. 

a. Document patient outreach as directed (within EMR and site spreadsheets).

b. Assist with scheduling TCM appointments, monitoring follow-up visit status.

3. Navigate Groupwise email system to read, send, and respond to messages appropriately and in a timely manner.

4. Use company’s EMR to send messages, input data, track results, navigate encounters, and update health care team.

5. Possess extensive knowledge of medical terminology, disease processes, diagnoses, and various payer requirements/guidelines/coverage.

6. Assist with triage and emergencies as needed.

7. Maintain excellent customer service skills in dealings with patients, coworkers, and community resources

8. Maintain patient confidentiality.

9. Develop an understanding of the use and functionality of up to 10 internet-based platforms for the management of patient care across all payers.

10. Develop and maintain a strong relationship with MPCP Care Management/Population Health team members.

11. Employ use of EMR’s quality measures dashboard to improve site’s compliance with merit-based incentive payment systems (MIPS).

12. Attend meetings, educational sessions, and community relationship meetings as needed/scheduled in order to foster the growth of the program, expand the reach of MPCP, and improve patient outcomes in the community.

13. Complete reviews of gaps in care across all payers to improve compliance, positively impact the current state of health and outcomes of the site’s patient population.

14. Oversee the scheduling and completion of Medicare Annual Wellness visits.

15. Organize, schedule, and attend Patient and Family Advisory Council Meetings (PFAC) in collaboration with the site RN Care Manager, as required.

16. Complete reports on the state of the site’s AHEAD program in collaboration with the site practice manager and RN care manager.

17. Understand how to use “Find Help” within EPIC and provide patients with appropriate information on community resources. 

a. Be able to guide patient on use of “Find Help” via the patient portal

18. Maintain a list of current, appropriate, vetted community resources & other healthcare organizations to promote improvement of patient outcomes, prevention of readmission, and well-rounded transition of the patient back into the community post-discharge.

19. Attend monthly Clinical Coordinator meetings, monthly interdisciplinary meetings, and site population health meetings as scheduled. 

Performance Requirements

Knowledge, Skills, and Abilities: Knowledge of the principles and skills needed to provide quality patient care including but not limited to the following: medications, exams, diagnoses, pathophysiology, diagnostics, and current standards of care. Must maintain records, using appropriate documentation, and follow-through. Candidate should be skilled in establishing and maintaining effective working relationships with patients, medical staff, and the public. He/she should be able to demonstrate competency in the use of Microsoft Office products- especially Microsoft Excel- for the development of workflows, tracking, and monitoring of patients. Ability to communicate clearly, professionally, and effectively by phone, email, fax, letter, or in person. Ability to multi-task by balancing numerous ongoing, in-process (unfinished) projects at one time. Ability to work autonomously on all projects while independently meeting deadlines and being evaluated by outcome measures.

Education: completion of an accredited medical assistant program and either certification or registration as a medical assistant.  

Experience: Three or more years of work in an ambulatory setting, preferably with at least one year of care coordination/clinical coordination experience

Certificate/Registration: CMA or RMA and continued recertification

MMR and Flu Vaccinations required (unless approved for a medical or religious exemption)

PPD

Background Check and Drug Screening required