Ambulatory Care Coordinator

JOB SUMMARY
As a part of the Care Team, responsible for identifying and facilitating "Gaps in Care" (GIC) services for patients in need of enhanced Care Coordination services. Also responsible for assisting the Care Team with the tracking and coordination of timely, high quality and efficient health care and support services as identified through a multi-disciplinary care plan, self-management goals and referrals to both internal and external resources. Provides administrative support by performing appointment outreach, facilitating referrals, updating patient information in medical records and assisting with data collection, aggregation and analysis activities.

Key Job Responsibilities

• Perform stratification of member populations into targeted subsets, using information collected through population assessment and other data sources, aimed at health promotion and wellness, management of chronic conditions and complex case management.
• Perform continuous Quality and Performance Improvement activities as assigned.
• Maintain surveillance ticklers and/or work with Health Information Technology (HIT) to proactively identify the need for patient care and outreach as assigned.
• Track and support patients when they obtain services outside the practice like Emergency Departments, Hospitals and other health care facilities.
• Follow-up with patients as prescribed after an emergency department (ED) visit or hospital discharge.
• Work with patients both in person and over the phone to remind and review their plan of care and progress towards their goals.
• Assist patients with the process of determining eligibility, obtaining and maintaining free pharmaceuticals through the internal pharmacy subsidy program.
• Collaborate with other members of the Care Coordination and Management team for activities including assistance with implementation of Care Plan.
• Manage referrals, when needed, to appropriate agencies required to assist the client in achieving the goals and objectives identified in their Care Plan.
• Identify and utilize cultural and community resources.
• Establish and maintain relationships with identified service providers.
• Assist with data collection and generation of patient registry reports.
• Ensure timely documentation in the Electronic Health Record (EHR).
• Demonstrate excellence in both internal and external customer service.
• Understand and effectively communicate HIPAA compliance, corporate compliance and client confidentiality.
• Ensure and/or remain in compliance with local, state, and federal regulation.
• Adhere to the National Patient Safety Goals as defined by Joint Commission and adopted by Ambulatory Administration and Services.

Required for All Jobs

• Performs other duties as assigned
• Complies with all policies and standards

Physical Demands

• Standing - Constantly
• Walking - Constantly
• Sitting - Frequently
• Lifting - Frequently
• Carrying - Frequently
• Pushing - Occasionally
• Pulling - Occasionally
• Climbing - Occasionally
• Balancing - Occasionally
• Stooping - Frequently
• Kneeling - Frequently
• Crouching - Frequently
• Crawling - Occasionally
• Reaching - Frequently
• Handling - Frequently
• Grasping - Frequently
• Feeling - Constantly
• Talking - Constantly
• Hearing - Constantly
• Repetitive Motions - Constantly
• Eye/Hand/Foot Coordination - Constantly

QUALIFICATIONS

Successful completion of an approved Medical Assistant program. Required

Minimum 1 year experience. Experience working with patients in a health care setting. Required

Managing competing priorities, medical terminology, public speaking, group training and project coordination desired.

Requirement AD, LPN or CMA licensure to work in the state of Tennessee.

Upon Hire Required and

CPR/BCLS - Basic Life Support Upon Hire Required