Job Overview: Valley Community Healthcare is seeking a dedicated and compassionate Care Coordinator to become an integral part of a comprehensive care team. The ideal candidate will play a pivotal role in facilitating transitions of care, addressing care gaps, conducting high-risk patient follow-ups, coordinating referrals, screening for Social Determinants of Health (SDOH), and providing patient education for their care team panel. This position requires strong communication skills, attention to detail, and a commitment to improving patient outcomes through comprehensive care coordination. This position will be an embedded care coordinator dedicate to the panel of two providers, focusing on patients in the risk tiers 1 and 2.
Responsibilities:
- Transitions of Care:
- Using various external sources (Lanes, PointClickCare, etc) outreach to patients from the providers’ panel that have had a recent hospital or ED discharge. Facilitate smooth transitions between healthcare settings, ensuring continuity and coordination of care for patients moving between hospital, home, and other care environments.
- Collaborate with healthcare providers, case managers, and other stakeholders to retrieve patient records and implement transition plans that prioritize patient seeing their primary care provider.
- Care Gap Outreach:
- Utilizing outreach lists developed by the QI data team, address cancer screening and chronic disease care gaps for the providers’ panel of patients. Follow established protocols and workflows to ensure patients care gaps are being addressed.
- Outreach should utilize various modalities of communication including texting, communication with the care team for ‘in reach’ and calling the patients for visits
- Work closely with healthcare providers to develop strategies for closing care gaps and improving overall patient care quality.
- High-Risk Follow-ups:
- Utilizing abnormal labs reports and following established protocols, ensure appropriate follow up is done for patients with abnormal or high risk labs.
- Collaborate with the healthcare team to develop and implement personalized care plans for high-risk individuals.
- Referrals Coordination:
- Manage the follow up of external referrals for the assigned providers’ panel, ensuring appropriate documentation and follow up with the patient. This could include but is not limited to…
1. Follow up with patient for referral status and specialist visit information.
2. Following up with the specialist for records and ensuring provider reviews.
3. Updating referral information in the patient chart.
· Utilize different modalities to communicate with the patient with updates to their referral status
- Social Determinants of Health (SDOH) Screening and Follow-up:
- Conduct screenings to identify social determinants impacting patients' health and well-being for the providers’ panel.
- Work with provider to develop appropriate action plan for the patient and utilize partner resources to link patients to needed external services
- Patient Education:
- Provide education to patients and their families regarding the importance of healthcare screenings, ER/Hospital usage, and emerging diseases (elevated BP, pre-diabetes, etc).
- Utilize educational materials in NG and resources to empower patients to actively participate in their healthcare journey.
Qualifications:
- Bachelor's degree in nursing, social work, healthcare administration, or a related field.
- Previous experience in care coordination, case management, or a related healthcare role. MA experience preferred.
- Knowledge of healthcare systems, transitions of care, and patient-centered care principles.
- Strong communication skills and the ability to collaborate effectively with multidisciplinary healthcare teams.
- Understanding of social determinants of health and their impact on patient outcomes.
- Proficiency in using electronic health records and other healthcare management software.
These specifications are general guidelines based on the minimum experience normally considered essential to the satisfactory performance of this job. Individual abilities may result in some deviation from these guidelines.
Job Type: Full-time
Pay: $22.00 - $24.00 per hour
Expected hours: 40 per week
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Employee assistance program
- Employee discount
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Pet insurance
Schedule:
- 8 hour shift
- Monday to Friday
- Weekends as needed
Work setting:
- Clinic
- In-person
- Office
- Outpatient
Experience:
- Outpatient: 1 year (Preferred)
- Case management: 1 year (Preferred)
Language:
Ability to Relocate:
- North Hollywood, CA 91605: Relocate before starting work (Required)
Work Location: In person