Care Coordinator

NorthShore Health Centers; Portage (IN); On-site; USD 42,000 - 64,000; Full time

Job summary

NorthShore Health Centers is seeking a Care Coordinator to support the ambulatory care team in Portage, Indiana. This role focuses on coordinating the health needs of patients with chronic conditions, preventive care, and healthy behaviors, working closely with the patient’s PCP and psychiatric consultant.

You will educate patients, help develop individualized care plans with SMART goals, and ensure timely documentation in the EHR.

Qualifications

• 1 year of care coordination experience.
• Community Health Worker Certification within 1 year of hire.
• CPR certification.
• Bilingual preferred.

Responsibilities

• Communicates to patients the purpose of the program and its impact on wellbeing.
• Helps patients identify social determinants of health and develop plans and SMART goals.
• Educates patients on appropriate ER use and alternatives.
• Assists patients in understanding care plans and instructions.
• Motivates patients to be engaged in their health and care.
• Develops an individualized plan of care with targeted interventions.
• Communicates with the care team/PCP to exchange updates on progress.
• Ensures age-appropriate health assessments are completed and documented.
• Maintains knowledge of community resources and NorthShore services.
• Completes transitions of care for ER/IP visits within 72 hours and documents findings.
• Closes the loop on external referrals and obtains records.
• Addresses care gaps and documents results in the EHR.
• Assists with requests for DME, home health, FMLA, etc.
• Performs glucose testing, CGM placements, vital signs as assigned.
• Provides follow-up to assess progress and provide barrier-crossing strategies.

Skills

Analytical thinking

Interpersonal skills

Communication skills

Time management

Attention to detail

Emotional intelligence

Problem solving

Education

Community Health Worker Certification within 1 year of hire

CPR certification

Tools

Microsoft Office

Job description

Summary/ObjectiveThe Care Coordinator is a core member of the care team, including the patient’s medical provider and psychiatric consultant, and the larger primary care team. The Care Coordinator is responsible for supporting and coordinating the overall health of patients, with a focus on chronic conditions, preventative care, and healthy behaviors.Essential FunctionsCommunicates to patients the purpose of the program and the impact it may have on their wellbeing.Helps patients identify social determinates of health that affect their overall health and develop health and social management plans and goals.Educates the patient on the proper use of the emergency room and provides information for alternatives.Assists patients in understanding care plans and instructions. Motivates patients to be active and engaged participants in their health and overall wellbeing.Responsible for developing a comprehensive individualized plan of care and targeted interventions incorporating the patient’s preferences and SMART goals.Effectively communicates with the patient’s care team / PCP to exchange information about the patient and give updates on progress made with self-management support services.Ensures age applicable health assessments/screenings are completed timely and documented in the electronic health record appropriately.Continual development of knowledge and understanding of community resources, NorthShore services, and programs offered.Completing transitions of care for ER/IP visits for patients within 72 hours of discharge and documenting findings appropriately in the patient's electronic health record.Closing the loop on all external referrals and obtaining outside records and results.Addressing gaps in care and documenting results in the patient’s electronic health record.Assists with patient/provider requests for durable medical equipment, home health services, FMLA requests, etc.Completes glucose testing, Continual Glucose Monitoring Device (CGM) placements, basic vitals, and other tests assigned by management.Provides follow up to patients to find out if they are meeting goals and how they are managing health issues, celebrates successes, and provides suggestions to overcome barriers to care.Maintains top quality proficiencies across all training areas in daily work.Attends meetings and training sessions as required.Executes other assigned tasks as requested by management.*These essential functions are a summary of the primary duties and responsibilities of the position and are not intended to be a comprehensive listing of all duties and responsibilities. The position will include other duties as assigned and duties are subject to change at the management's discretion.CompetenciesPlanning and strategic foresightResponsible Decision Making and Problem SolvingIntegrity and accountabilityInnovation and creativityAdaptive and flexibleLeadership, teamwork, and conflict resolutionProfessionalism and work ethicEmpathyWork EnvironmentWork is performed in an ambulatory care environment. Involves frequent personal and telephone contact with patients, physicians, and other healthcare personnel. Work may be stressful at times. Interaction with others is constant and interruptive.TravelTravel outside of Northshore locations will be rare for this position.Required Role QualificationsMinimum required education per state of Indiana/HRSA1 year of care coordination experienceCommunity Health Worker Certification within 1 year of hireValid CPR certificationPreferred Role QualificationsTwo years of experience working within a healthcare setting.Certified/Registered Medical Assistant, Licensed Practical Nurse, Advanced Practical Nurse or Registered Nurse licensingBilingual preferredRequired SkillsAbility to analyze situations and solve problems at strategic and tactical levelsExcellent interpersonal and customer service skillsAbility to comprehend, interpret, and apply the appropriate sections of applicable laws, guidelines, regulations, ordinances, and policiesAbility to acquire a thorough understanding of the organization's hierarchy, jobs, qualifications, compensation practices, and the administrative practices related to those factorsPracticed at organization and planningEmploy Critical thinking and problem solvingMaintains composure and operates with emotional intelligenceEthical reasoning and decision-makingStrong attention to detailReceptive and responsive to feedbackExcellent verbal and written communication skillsTime management, prioritization, and sense of urgencyProficient with Microsoft Office Suite or related softwarePhysical, Visual, and Audible RequirementsPhysical RequirementsActivityOccasionally (1 -33%)Frequently (34-66%)Continuously (67-100%)SittingXWalkingXStandingXBendingXSquatting/CrouchingXClimbingXKneelingXTwisting/TurningXHand dexterity/Fine Motor ManipulationXLifting 0 – 50lbsXLifting 50+lbsXCarrying 0 – 50lbsXCarrying 50+lbsXPushing 0 – 300lbsXVisual & Audible Requirements – Employee mark an “x” for “YES” or “NO”ActivityYesNoCan see without corrective eyewearCan differentiate colors/see color differences clearlyCan hear without hearing assistanceI acknowledge that I may be exposed to infectious and contagious diseases.I acknowledge that I may be in contact with patients under a wide variety of circumstances.I acknowledge that I can handle and respond to emergency or crisis situations per NorthShore Health Centers facility plans, protocols, and procedures.I acknowledge that I may occasionally be subject to irregular working hours.I acknowledge that I may be required to wear personal protective equipment (PPE) as necessary.*Reasonable accommodations can be made to enable people with disabilities to perform the essential functions of the job described.