Care Coordinator

002 Sea Mar Community Health Center; Everson (WA); On-site; USD 46,000 - 48,000; Full time

Benefits offered by this job

Medical

Dental

Vision

Prescription coverage

Life Insurance

Long Term Disability

EAP

PTO 24 days/year

10 holidays

Job summary

Sea Mar Community Health Centers is seeking a Care Coordinator to support patient care in a busy community health setting. You will participate in huddles, identify gaps in care, and link patients to behavioral health and community resources.

The role emphasizes advocacy, timely follow-ups, and coordination across the care team. The ideal candidate has Medical Assistant training, CPR certification, and Spanish language skills, with experience in a community health environment.

Qualifications

• Medical Assistant Training with one or more years of experience in a community health setting.
• Current CPR certification within 90 days of hire.
• NCQA certification is a plus.
• Valid WA State Driver’s License and proof of liability insurance.
• Bilingual in Spanish is strongly preferred.

Responsibilities

• Participate in morning huddles to anticipate the patient’s clinical, social and behavioral health needs.
• Identify gaps in care with the care team and resolve them using process improvements.
• Provide brief interventions at point of care to support chronic illness management and link patients to behavioral health services.
• Advocate for patient services with community, social service, and medical providers.
• Coordinate care transitions for patients seen in emergency rooms or discharged from facilities.
• Connect patients to Sea Mar resources and track available services such as insurance enrollment and preventive care.
• Demonstrate excellent customer service and confidentiality; maintain 340b medication assistance where applicable.
• Other duties as assigned by Health Center Administrator or Program Manager.

Skills

Bilingual in Spanish

Critical thinking

Organizational skills

Communication skills

Customer service

Confidentiality

Education

Medical Assistant Training

CPR Certification

WA Driver's License

Tools

Microsoft Office

Electronic Health Records

Job description

Sea Mar Community Health Centers, a Federally Qualified Health Center (FQHC) founded in 1978, is a community-based organization committed to providing quality, comprehensive health, human, housing, educational and cultural services to diverse communities, specializing in service to Latinos in Washington State. Sea Mar proudly serves all persons without regard to race, ethnicity, immigration status, gender, or sexual orientation, and regardless of ability to pay for services. Sea Mar's network of services includes more than 90 medical, dental, and behavioral health clinics and a wide variety of nutritional, social, and educational services.

Duties and Responsibilities

Sea Mar is a mandatory COVID-19 and flu vaccine organization. As a mission-driven organization, the core values of, and the services offered at Sea Mar are based on the belief that everyone deserves to be respectfully treated in a way that preserves dignity and enhances selfworth. Sea Mar is an advocate for its clients and aims to achieve industry-leading, client-centered, culturally aware services. Sea Mar employees serve as an extension of this mission and demonstrate their commitment to an excellent client experience by:

• Understanding and empathizing with client needs
• Surpassing client expectations
• Demonstrating a high level of integrity
• Exhibiting compassion and commitment
• Advocating for social justice
• Taking pride in individual work as well as that of the team
• Continuously learning to stay current with industry standards, best practices and technology

As a Sea Mar employee, the individual in this position commits to adherence to these values to their utmost ability and endeavors to strengthen and embody this mission daily. The following is a list of duties and responsibilities for the care coordinator:

Patient Care Coordination

• Participate in morning huddles to anticipate the patient’s clinical, social and behavioral health needs.
• Work with the care team to identify gaps in care and work to resolve them using process improvement strategies.
• Provide brief interventions at point of care to assist patients with management of their chronic illness, address any social needs and link patients to behavioral health.
• Send letters and perform follow-up phone calls to patients for planned visits.
• Advocate for patient services with community, social service, and medical providers.
• Participate and coordinate care transitions for patients who have been seen in an emergency room and/or have been discharged from a hospital/long-term care facility.
• Connect patients to Sea Mar and non-Sea Mar resources as appropriate and track all resources available to patients. These services may include but are not limited to insurance enrollment, preventive health services, behavioral health, dental, and care management.
• Assist patients with ongoing self-management goal setting based on mutual goal setting and with emphasis on client decision-making utilizing motivational interviewing skills.
• Follow up with patient to evaluate their condition and address barriers to care plan.
• Track patient’s adherence with plan of care in electronic or paper charts and communicate outcomes and recommendations to the primary care provider.
• Participate in group visits and planned visit events providing care coordination support.
• Disseminate information regarding care for chronic illnesses and/or mental health and behavioral issues to the clinical care team.
• Maintain indigent patient medication assistance program and dispense 340b medications and supplies depending on the clinic site.
• Exhibit excellent customer service skills by using active listening skills, greeting patients in a welcoming manner, making them their only priority when providing services and assist in meeting the patients’ needs.
• Other duties as assigned by the Health Center Administrator and/or the Health Education & Care Coordination Program Manager.

Quality Improvement

• Function as a point person within the clinic care team regarding chronic disease management and improvement activities to improve clinical quality measures.
• Identify patients for gaps in care that need to be addressed in the huddle.
• Organize monthly Health Home meetings by working with the Clinic Operations Team/Clinic Manager, create the agenda and help facilitate the meeting.
• Track and promote quality improvement initiatives related to chronic care (chronic disease) and behavioral health integration.
• Submit PDSA activities to the Clinic Manager on a monthly basis as part of the QI process.
• Work closely with care team members and hold team meetings monthly or as needed when implementing new systems.
• Collaborate with clinical care team to improve Patient-Centered Medical Home processes and provide documentation demonstrating performance.
• Generate reports for care teams to identify areas of improvement and monitor sustainability of each quality measure.
• Review the medical record for quality and utilization indicators according to the Quality Improvement Plan.
• Train new clinic staff on the Chronic Care Model and Patient-Centered Medical Home.
• Participate in inviting patients to set up their Follow My Health account and provide brief information about the benefits of it.
• Other duties as assigned.

Qualifications

• Must be able to work independently, prioritize workload, and meet deadlines.
• Must have critical thinking skills and maintain confidentiality.
• Excellent organizational skills and ability to handle a variety of tasks simultaneously.
• Knowledge of medical terminology and/or behavioral health topics.
• Strong decision making and prioritization skills.
• Ability to work respectfully and professionally with the community, patients, families and staff.
• Able to work effectively in a multi-cultural environment with a diverse population.
• Sympathetic, mature, responsible, and reliable.
• Strong patient engagement, interpersonal, and communication skills and ability to establish a therapeutic relationship with the patient.

Knowledge, Skills, and Abilities

• Knowledge of the Patient-Centered Medical Home Model and motivational interviewing skills a plus.
• Knowledge of evidence-based standards of care for chronic conditions and behavioral health issues.
• Knowledge of and proficient in Microsoft Word, Excel, PowerPoint, and Outlook.
• Ability to utilize and document relevant patient information the Electronic Health Record.
• Knowledge of community resources.
• Ability to work in a fast-paced community health care setting.
• Ability to think analytically and problem solve in a multidisciplinary team and independently.
• Ability to deal effectively with difficult people and situations.
• Ability to communicate effectively with diverse communities.
• Ability to manage time effectively and prioritize tasks.
• Ability to analyze patient care data.
• Ability to identify client learning needs and to assess client's knowledge, skill level and readiness for learning.
• Ability to maintain the privacy and security of sensitive and confidential information in all formats including verbal, written and electronic; and adhere to policies and procedures related to local, state, and federal privacy requirements.
• Excellent communication and customer service skills.
• Critical thinking skills.
• Ability to understand and implement process improvement activities.
• Bilingual in Spanish is strongly preferred. Other language skills may be considered depending on site needs due to the population that is being served.

Reasoning Ability

• Must be able to work independently, have good problem-solving skills and be open to change processes.

Education, Certificates, Licenses, and Registrations

• Medical Assistant Training with one or more years of experience in a community health setting or family practice, or, one or more years of equivalent experience. Current licensure is not required for this position.
• This position must obtain CPR within 90 days of hire date and is required to maintain current CPR throughout employment.
• NCQA (National Committee for Quality Assurance) Certification is a plus.
• Valid WA State Driver’s License and proof of liability insurance.

Medical Screening Requirements

• Pre-hire and annual employee health screening required.
• Annual influenza vaccine required. Only exception is for employees with a medical or religious exemption approved by Administration. Employees with an approved medical or religious exemption must wear a mask at all times during the flu season.
• COVID-19 Vaccination is a mandatory condition of employment.

Work Environment

This position entails sitting and working at a computer for long periods of time and working in a shared space with ambient noise and other distractions, and other conditions typical of an office environment. While performing the duties of this job, this employee is regularly required to communicate by telephone. This position also entails working in a fast-paced ambulatory medical clinic setting requiring much walking, standing, and sitting repeatedly.

Physical Requirements

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions. While performing the duties of this job, the employee is regularly required to use hands to finger, handle or feel; reach with hands and arms; and talk or hear. The employee frequently is required to walk, stand and stoop and occasionally required to kneel, crouch or crawl. The employee must be able to lift and/or move up to 20 plus pounds. Specific vision abilities required by this job include close, distance, color and peripheral vision including the ability to have depth perception and adjust focus.

Hourly - Hourly Plan, 22.54 USD Hourly

Hourly - Hourly Plan, 22.54 USD Hourly

What We Offer

Sea Mar offers talented and motivated people the opportunity to work in a dynamic and growing community health organization. Working at Sea Mar Community Health Centers is more than just a job, it’s a fulfilling career with opportunity for advancement. The fringe benefits surpass most companies. For example, Full-time employees working 30 hours or more, receive an excellent benefit package of:

• Medical
• Dental
• Vision
• Prescription coverage
• Life Insurance
• Long Term Disability
• EAP (Employee Assistance Program)
• Paid-time-off starting at 24 days per year
• 10 paid Holidays
• 401(k)/Retirement options

We also offer 401(k)/Retirement options and an exciting opportunity to work in a culturally diverse environment.

Sea Mar is an equal opportunity employer. Please visit our website to learn more about us at www.seamar.org. Sea Mar Community Health Centers, founded in 1978, is a community-based organization committed to providing quality, comprehensive health, human, housing, educational and cultural services to diverse communities, specializing in service to Latinos in Washington State. Sea Mar proudly serves all persons regardless of their ability to pay for services. Sea Mar's network of services includes more than 90 clinics.