Position Summary The Care Coordinator will be an integral member of the care management team. Responsible for assisting the team in providing outreach efforts to patients currently receiving care management services. This role will utilize the established model of case management to support the care teams. Exemplifies the CCHC mission, vision and values and acts in accordance with CCHC policies and procedures, including complying with all CCHC Customer Service Standards. Responsibilities Monitors Medical Home Network (MHN) portal. Gathers and delivers required documents for care management model, including but not limited to medical records outside of CCHC, referral/consult notes, and post hospitalization records. Involved in the initial patient screening process, initial patient survey, reminder patient phone calls, as well as providing education under the guidance of the care team. Follows up with patients in the hospital/clinic setting as needed. Audits patients' records. Work across all payor panels. Serves as a trained health coach to patients (CCHC will provide motivational interviewing training) Connect patient and Medical Home to needed community-based services, providing care management. Assists patients in utilizing healthcare services and referrals that are both in and out of their individual insurance plan. Schedules appointments and monitors compliance with keeping appointments. Documents all correspondence in MHN portal and electronic medical records, as necessary. Collaborates with patient's Medical Home to arrange conference calls as needed. Collaborates with the care management team to develop the patient's individualized care plan. Works with care team to improve identified outcomes by using MHN quality measures. Works with care team to identify extrinsic barriers to adherence (i.e. transportation, financial concerns or pharmacy) and works with patient and team to alleviate barriers. Acts as a liaison to multiple departments, agencies, and provider offices. Performs related duties as assigned. Qualifications High school diploma or equivalent required. No licensure required. At least three years of experience in a medical office; experience working in an ambulatory environment required. One to three years of experience with electronic medical records. Medical Assistant program completion preferred. Knowledge of the needs of highly complex patients. Strong verbal and written communication skills and interpersonal skills. Good organizational skills. Ability to multi-task and be self-motivated. Ability to work effectively independently and as part of a team. Bilingual highly desirable.