Position Summary: Under the direction of Supervisor, the PACE Clinical Coordinator is part of the primary care practice team and is responsible to assist with coordinating and providing panel management and population health services to patients within the practice who are at most risk for health deterioration or poor outcomes. The PACE Clinical Coordinator's role is to improve health outcomes through scheduling preventative and maintenance care appointments, educating patients, building the medical home between patients and practitioners and enhancing communication and continuity of care. The PACE Clinical Coordinator uses a culturally-sensitive approach with all patients - in person, by telephone, or web portal. The PACE Clinical Coordinator works with the Care Team to increase patient's access to appointments, services and health care resources thereby, supporting patient's self-care management goals. The PACE Clinical Coordinator is also responsible for prior authorization processing.
Essential Functions of the Job:
Facilitates patient flow by preparing patient charts for providers. This will be done by checking to see if laboratory or x-rays were ordered at last visit and ensure that they are in the charts prior to the visit.
Takes vital signs, calculates BMI, and documents patient's chief complaints and medical history.
Documents and keeps accurate charting of patient care given as required by department and profession.
Immunizations coordinator and back-up must comply with all listed immunizations quality assurance measures.
Prepares exam rooms and patients for examination and assists provider during examinations as directed.
Performs procedures such as assisting with suturing, inhalation treatments, EKG, visual testing, audiometric testing and preparing/obtaining lab specimens.
Utilizes the Primary Care Medical Home model to provide coordinated Team Care that addresses current diseases and provides panel management for preventative and health maintenance follow-up for the maximum number of patients per day.
Educates patients on the coordination of care and answers patient questions when appropriate.
Schedules patients with chronic conditions for follow-up appointments per preventative & maintenance care schedules. Performs population management tasks such as appointment scheduling, recalls, web portal callbacks, and addressing telephone encounters.
Makes outreach calls to patients missing appointments based on preventative and chronic disease guidelines.
Answers, screens and directs phone calls into department as needed.
Provides translation, verbal or written as necessary, if bilingual.
Implements actions for increasing productivity such as, scheduling patients for PCP follow up visits, anticipating open slots for same day appointments and proactively maintaining full provider schedules.
Meets weekly with the Care Team to identify and implement actions for improving population management outcomes.
Organizes weekly pre-clinic team huddles to update on progress of various goalssuch as Meaningful Use PCMH, compliance, and other pertinent goals.
Coordinates monthly Clinical Coordinator team meetings with clinic site Registered Nurse to discuss progress towards PCMH goals and areas needing improvement.
Provides end-of-visit interviews, coaching and patient engagement conversations when necessary and documents in EHR.
Reinforces information given to the patient and/or family with handouts to improve patient self-management skills and communication.
Provides as-needed teaching to patients during medical appointments.
Acts as a point of contact for patients and families for asking questions and raising concerns via phone or in person.
Participates as a member of the multi-disciplinary Care Team.
Works in Services Coordination with other disciplines and patients as needed.
Functions at highest level of licensing and competency.
Positively impacts patient experience by demonstrating values of Transforming Care including, but not limited to courteous and helpful behavior and a commitment to accuracy.
Shares accountability for overall patient health outcomes, working in coordination with Care Teams.
Operates to instill confidence in our care and in our facilities to patients, fellow employees, and other stakeholders.
Other duties as assigned.
Additional Duties and Responsibilities:
Uses a step-by-step process when teaching skills.
Uses positive reinforcement and encouragement.
Uses a flexible approach with a diverse population.
Attends both mandatory in-service trainings and related meetings, providing feedback to staff on the content of educational programs attended.
Occasionally, coaches patients to address critical issues using motivational interviews and helps patients develop achievable self-management care plan goals.
Works in cooperation with coworkers and supervisory staff.
Communicates effectively with staff and the public.
Able to use critical thinking to make decisions and problem solve.
Accepts and uses direction and supervision.
Ability and willingness to self-motivate, prioritize, and be agreeable to change processes to improve effectiveness.
Interacts in a manner which is professional, respectful, positive, helpful, and promotes trust.
Demonstrated ability to work and communicate with people from various ethnic, socio-economic, educational and experiential backgrounds.
Education Required (Minimum level of education): Current MA certificate. MA experience -preferably working with the medical home concept.
Certifications/Licenses Required: Valid driver's license and access to a dependable insured vehicle. Able to travel to meetings, as needed.
Experience Required (Minimum level of experience): Minimum of 2 years MA experience.
Verbal and Written Skills Required to Perform the Job: Excellent interpersonal skills. Good written and verbal communication skills. Bilingual English/Spanish required.
San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family.
The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 92,000 patients through a vast and integrated network of 34 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees.
Apply today and become a part of our mission-driven team!
San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment. Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to reace, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.
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