Enhanced Care Management Care Coordinator

Job Summary: This position is responsible for assigned social work case management functions for Omni Family Health (OFH). The primary duty of the ECM Care Coordinator is to identify and assist members that are displaying a complex variety of social and/or emotional needs and usage of services reflective of abuse, lack of compliance to medical or pharmaceutical instructions, or self-destructive habits. The care coordinator makes arrangements with these members and the member's primary care provider in an effort to provide better medical management and to track and gauge the effectiveness of that effort.

The ECM Care Coordinator will work closely with a multi-disciplinary team in the health home model, outpatient case management and primary care to develop and provide clinical services that are necessary to achieve an extended healthcare focus beyond the inpatient setting or traditional primary care of specialist office visits. The care coordinator will plan and implement medical social service delivery programs, promote coordination, continuity of care, and quality management in support of ECM members/patients. This position serves as a liaison to all ECM staff, providers, and members to provide services.

Job Duties:

• Engage with members in the Enhanced Care Management (ECM) Program.
• Monitor treatment by completing and keeping up-to-date Care Plans in conjunction with provider recommendations related to chronic conditions and health needs.
• Provide health promotion and self-management training.
• Make frequent calls to the ECM members.
• Establishes and maintains interpersonal relationships with both internal and external staff and other agencies.
• Assists members and/or families/significant others, regarding discharge issues and transition of care needs.
• Provides care coordination in conjunction with other case management staff and community providers in emergency and non-emergency situations.
• Participates in medical appointments as necessary to ensure continuity of care and follow through with care plan goals and needs.
• Documents interactions with members and providers as required and maintains records of referral interactions with behavioral health, food security entities, housing referrals and other community resources.
• Has the ability to independently assess the psychosocial functioning needs of patients and their family members and to formulate and implement a treatment plan, identifying the patient's problems, strengths, weaknesses, coping skills and assistance needed, in collaboration with the patient, family and interdisciplinary treatment team.
• Other duties related to ECM as assigned.
• Home visits if indicated.

Job Requirements:

• Excellent written, verbal and interpersonal communication skills.
• Have strong leadership with ability to integrate multi-disciplinary teams.
• Ability to demonstrate knowledge and experience of complex systems of care.
• Ability to work under pressure.
• Ability to work independently and follow through on assignments with minimal direction.
• Ability and willingness to treat all patients with the utmost kindness and consideration in the most trying situations.
• Friendly personality with the desire to work with the public.
• Ability to handle multi-functions.
• Understanding of community based organizations.
• Promotes and believes in OFH mission statement.
• Ability to relate to the public regardless of ethnic, religious and economic status.
• Must be willing to work at any Omni Family Health, location, other that the assigned site and be agreeable to work weekends, if so needed.
• Must have active Basic Life Support Certification from the American Heart Association.
• Commitment to the concepts of preventive health care program and team approach to health care delivery.

Additional Duties:

• Health Insurance Portability and Accountability Act (HIPPA) Compliance: Responsible for maintaining abreast of and in compliance with all HIPPA regulations and requirements.
• Compliance: Ensures compliance with all local, state, and federal regulations.
• Quality Assurance/Quality Improvement (QA/QI): Participates as required in QA/QI activities and contributes towards the overall quality improvement initiatives of the organization.
• Information Technology (IT): May be required to learn and use the electronic health record and its components as required by the job functions and highlighted in the policies and procedures. These components include NextGen, Practice Management System (PMS), Quality Systems Inc. (QSI), and other electronic features as they are developed and implemented, as applicable to work environment.
• Patient Centered Medical Home (PCMH): All employees will participate in PCMH at Omni Family Health.
• Audits: Contributes to required Health Resources and Services Administration (HRSA), Operational Site Visit (OSV), The Joint Commission (JC), and other audit events.

Qualifications, Education, and Experience:

• Two years in care coordination service delivery.
• Must hold one of the following at minimum: Medical Assistant Certification or Associates Degree in Healthcare Administration, Healthcare Management, Medical Office Administration, or related field.
• Previous patient centered medical home and NCQA knowledge a plus.
• Bilingual in English/Spanish preferred.

Responsible to: Enhanced Care Management Supervisor

Classification: Nonexempt