PCMH+ Care Coordinator

Community Health Center, Inc. – Connecticut

Job Description Summary: Community Health Center, Inc. (CHC), with offices in Connecticut, Colorado and California, is one of the country’s most creative and dynamic providers of primary medical, dental, and behavioral health services, and a leader in practice-based research, health professionals training, and use of innovative technologies to advance health and healthcare. CHC is designated as a federally qualified health center and a patient-centered medical home by HRSA, the Joint Commission, and NCQA, respectively. We deliver more than 500,000 patient visits per year from primary care hubs and community clinics across the state of CT, all connected by technology and common standards for quality. We employ several hundred medical, dental, and behavioral health providers who are engaged in practice, teaching, and research. Our Weitzman Institute is devoted to research and practice transformation and is recognized around the country as one of the premier research institutes focused on improving health care and health outcomes for special and vulnerable populations. In addition, the organization has developed three wholly owned subsidiaries from the original pilot developments within the Weitzman Institute: the National Nurse Practitioner Residency and Fellowship Training Consortium (NNPRFTC), the National Institute for Medical Assistant Advancement (NIMAA), and the Community eConsult Network (CeCN). Job Description: Care Coordination is essential to the Patient Centered Medical Home Plus model. Coordinating with primary care team members The care coordinator is responsible to schedule patient visits for those PCMH+ patients who have gaps in care for well child visits and those who miss scheduled appointments. The Care Coordinator is well versed in community support services and may attend some of the Integrated Care Team meetings. The Care Coordinator is responsible for helping the patient to keep established visits and problem solves when there are identified difficulties in keeping those appointments. The Care Coordinator works collaboratively with other members of the health care team as necessary including the primary care providers, medical assistants, behavioral health providers, nurses, medical assistants, Pharmacists, Access to Care staff and other ancillary staff as well as outside agencies. The main responsibilities of this position include coordinating patient care PRIMARY CONTACTS Supervisor - Daily Senior QI Manager - Weekly /monthly Operation Managers - Daily Primary Care Team members - As needed Pharmacies - As needed Community Behavioral Health Agencies - As needed PHYSICAL EFFORT/ENVIRONMENT Physical labor is minimal for this position. WORK SCHEDULE DEMANDS This position is full time unless otherwise noted in postings. COMMUNICATION SKILLS Excellent verbal and written skills are required. This position is highly involved with patients, staff, providers, colleagues and community resources. CONFIDENTIALITY OF INFORMATION Professional standard of confidentiality of patient records and conversations SIGNIFICANT JOB FUNCTIONS Identifies those patients who are need of scheduling well care visits from the share point dashboard report Maintains a tracking system to easily keep track of scheduling attempts and appointments Attends ICM’s with each Primary Care Team Utilizes innovative modes of communication to engage patients in committing to appointments and problem solving with them as needed Assists staff to identify any "navigation" issues to ensure that patients they are able to attend scheduled medical visits both at CHC and outside the agency Coordinates with the Operation Managers to schedule patients as needed Resolves challenging issues of community care coordination and resources that can't be managed by Access to Care staff TRANING REQUIREMENTS NOVO Centricity Share Point dashboards Location: Middletown – Weitzman Building Time Type: Full time

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