Patient Care Coordinator

Statement of Purpose

Under the direct supervision of the Program Manager. The Patient Care Coordinator is to support patients and coordinate with clinical staff, care providers, and community resources.

Major Tasks, Duties and Responsibilities

• Will take initiative in care coordination activities and communicating with patients and providers.
• Will assist with coordination of assistance programs (such as Medi-Cal or Covered CA) by connecting patients to resources.
• Serve as the main point-of-contact for patient intake for Health Center Network.
• Verify patient eligibility.
• Maintain accurate and up-to-date patient demographic and clinical information in the EHR.
• Document all communications to and from patients in the EHR in a timely and accurate manner.
• Communicate with providers on any situation that requires immediate assistance.
• Must be available for in-person consultations for high-acuity patients at any one of the BHS Health Center Network clinic sites or other BHS sites.
• Coordinates services based on providers care plan including coordination of appointment for medication administration or pharmacy fulfillment.
• Oversee intake, transfer of care and discharge activities for patients enrolled in specialty case management.
• Coordinate appointments, referrals, and follow-up. Schedule transportation when necessary.
• Coordinate with provider and patient for transfer of services to and from other providers or organizations.
• Maintain active list of patients in EHR, spreadsheet, registry, and or population health tool.
• Update risk status based on new events including review of health information exchange activity. (ER visit, missed meds, crisis call)
• Conduct scheduled outreach calls/texts/home outreach when appropriate.
• Check patient safety, symptoms, medication access, housing stability.
• Attempt re-engagement for unreachable patients.
• Participate in safety programs to promote patient and staff safety
• Maintain professional boundaries and standards of conduct.
• Treat patients with respect, care, and concern at all times.
• Maintain health and safety standards within the facility.
• Recognize personal biases and demonstrate cultural sensitivity when working with diverse populations.
• Attend meetings, trainings, and participate in committees as assigned.
• Perform other duties as assigned.

Patient Care Coordinator Competencies and Performance Expectations

• Ability to complete the above major tasks, duties and responsibilities
• Ability to demonstrate professional judgment and decision-making
• Ability to adhere to professional standards
• Support patients and coordinate with clinical staff, care providers, and community resources.
• Exercises sound judgment and appropriately escalates urgent or high-acuity patient needs.
• Communicates clearly and professionally with patients, providers, and care teams.
• Demonstrates strong organizational and time management skills to manage patient panels, outreach activities, and care coordination workflows.
• Be a compassionate professional who believes in facilitating wellness and recovery for patients and their families.
• Take initiative in instituting care coordination policies and communicating with patients and providers.
• Demonstrates the ability to serve as the main point of contact for intake, transfer of care, and discharge activities for patients enrolled in specialty case management programs offered by BHS Health Center Network.

Prerequisite Qualifications

Following are the qualifications required to perform the essential functions of this position. Qualifications may be subject to modification based on the Americans with Disabilities Act.

High school diploma or equivalent required.

Minimum two years of experience in an ambulatory clinic, medical office, FQHC, or Behavioral Health setting preferred.

Experience with electronic health record systems; eClinicalWorks preferred

Knowledge of patient registration, scheduling, referral coordination, and basic clinic workflow processes

Strong organizational, communication, and customer service skills

Proficiency in Microsoft Word, Excel, Outlook, and other basic computer systems

Ability to manage multiple priorities and work independently in a fast-paced environment

Must have valid California driver's license and liability insurance if driving personal or company vehicle on BHS business.

Ability to maintain confidentiality and comply with HIPAA regulations

Vision, hearing, manual dexterity and eye-hand coordination must be adequate for performance of job duties. Able to sit at desk, use keyboard, write and physically perform other job duties. Able to move about the facility to observe clients and staff.

Prerequisite Qualifications

Following are the qualifications required to perform the essential functions of this position. Qualifications may be subject to modification based on the Americans with Disabilities Act.

High school diploma or equivalency. Must be fluent in English and Spanish. Minimum two years experience in an ambulatory clinic setting and FQHC setting. Experience with Medi-Cal managed care and medically underserved populations. Experience with EMR programs (eClinicalWorks preferred). Knowledgeable of patient registration, basic clinic, flow, and patient tracking mechanisms. Ability to travel to BHS Health Center Network clinic sites throughout the week as needed. Experience using Microsoft Excel and Word.

Must have valid California drivers license and liability insurance if driving personal vehicle on BHS business.

Vision, hearing, manual dexterity and eye-hand coordination must be adequate for performance of job duties. Able to sit at desk, use keyboard, write and physically perform other job duties. Able to move about the facility to observe clients and staff.

Specific qualifications may vary based on assignment. The supervisor will initial those items on the following list, which apply and write N/A to indicate those qualifications, which are not applicable:

_____ Class B California Drivers License.

_____ Class C California Drivers License

_____ Personal vehicle with liability insurance for reimbursable mileage, generally short distances.

_____ First Aid certification, obtain within 90 days of employment and maintain current thereafter.

_____ CPR certification, obtain within 90 days of employment and maintain current

thereafter.

_ Bi-lingual (specify: ___)

_____ Develop computer skills adequate to perform Caminar/word processing duties within 90 days of employment.

Modality Specific Job Responsibilities

Duties may vary based upon assignment. Employee shall receive, concurrent with this job description.

The above statements reflect the general duties considered necessary to describe the principal functions of the job as identified and shall not be considered as a detailed description of all the work requirements which may be inherent in the position.