Value-Based Care Clinical Coordinator

The responsibilities of this job include, but are not limited to, the following: Assisting Nurse Care Managers (NCMs) by facilitating outside specialty referrals, scheduling diagnostic testing, or aiding in collaborative care efforts as directed; Coordinating external clinical resources efficiently according to NCM directives and care plans using the resources available; Collaborating with department leadership to support and improve the effectiveness and efficiency of clinical practices and processes; Understanding the electronic medical record system, NCM module, and payer-specific systems; Developing and maintaining strong relationships with patients, Patient First Physicians, ancillary staff, and external clinical support resources to ensure continuity of care; Conducting telephonic outreach to patients to encourage clinical gap closure, including: Providing telephonic advice per Patient First and Value-Based Care-specific instructions, maximizing the patients' health, wellness, safety, and self-care capabilities by closing care gaps and helping with coordination of patient self-care needs, and scheduling and facilitating conversations with NCMs; Educating patients and caregivers on the importance of specified preventive or chronic care gaps; Assisting patients with appointment scheduling; conducting follow-ups with patients to ensure compliance with recommendations and follow-up appointments as needed; Coordinating any necessary clinical information to support specialist appointments and transitions of care between in-patient, specialty, and primary care settings; Communicating necessary patient updates, escalating clinical needs, and ensuring an effective handoff has been made to the assigned NCM; Facilitating the transfer of all urgent and emergent calls to an NCM or the Quality Improvement Committee (QIC) Project Director; Developing a list of medical and community resources available to patients and maintaining collegial relationships with frequently used organizations; Facilitating continuity of care on behalf of the patient to ensure successful closure of care gaps; Fostering positive relationships with and effective communication between Patient First, consulting physicians, hospitals, and other frequently used health care resources; Assisting with the day-to-day operations and administrative needs of the NCM department; Completing assigned checklists within the assigned shift; Receiving and storing supplies, as well as restocking the NCM area as needed; Attending staff meetings as scheduled by the NCM Supervisor; Handling NCM requests in a timely manner; Operating and maintaining office equipment as trained. Minimum education and professional requirements include, but are not limited to, the following: Must be eighteen years of age or older; Associate degree preferred with at least 3 years of experience as a Medical Assistant, preferably within a Patient First center; Experience in scheduling appointments with multiple providers, including diagnostic testing; Ability to work in a team-oriented environment and be highly organized; Ability to work and communicate effectively with all levels of administrative and professional personnel; Exceptional oral, written, and telephonic communication skills; Self-disciplined, self-directed, motivated, energetic, passionate, and innovative; Must be able to sit, stand, and walk for long periods of time.