Care Coordinator - Chronic & Behavioral Health Support

002 Sea Mar Community Health Center; Lynnwood (WA); On-site; USD 60,000 - 75,000; Full time

Job summary

Sea Mar Community Health Centers in Washington state seeks a Full-time Care Coordinator at our Lynnwood Medical Clinic to coordinate care for patients with chronic conditions and behavioral health needs at the point of care. You will participate in daily huddles, identify patient needs per protocols, and contribute to patient-centered care quality.

As a member of the Clinical Care Team you will support care transitions, document outcomes, and collaborate to improve Health Home processes while

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 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.

Responsibilities

• Participate in morning huddles to anticipate the patient's clinical, social and behavioral health needs.
• 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.
• Advocate for patient services with community, social service, and medical providers.
• 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.
• Track patient's adherence with plan of care in electronic or paper charts and communicate outcomes and recommendations to the primary care provider.
• Function as a point person within the clinic care team regarding chronic disease management and improvement activities to improve clinical quality measures.
• Organize monthly Health Home meetings by working with the Clinic Operations Team/Clinic Manager, create the agenda and help facilitate the meeting.
• Collaborate with clinical care team to improve Patient-Centered Medical Home processes and provide documentation demonstrating performance.
• Review the medical record for quality and utilization indicators according to the Quality Improvement Plan.
• Generate reports for care teams to identify areas of improvement and monitor sustainability of each quality measure.

Skills

Critical thinking

Communication skills

Organizational skills

Confidentiality

Multicultural environment

Team collaboration

Patient engagement

Tools

Microsoft Word

Excel

PowerPoint

Outlook

Job description

Sea Mar Community Health Centers in Washington state seeks a Full-time Care Coordinator at our Lynnwood Medical Clinic to coordinate care for patients with chronic conditions and behavioral health needs at the point of care. You will participate in daily huddles, identify patient needs per protocols, and contribute to patient-centered care quality.

As a member of the Clinical Care Team you will support care transitions, document outcomes, and collaborate to improve Health Home processes while