Care Coordinator II

002 Sea Mar Community Health Center; Washington (Washington County); On-site; GBP 34,000 - 45,000; Full time

Job summary

Sea Mar Community Health Centers seeks a Care Coordinator to manage the coordination of care for patients with chronic conditions and behavioral health needs at the point of care. As a member of the Clinical Care Team, you will participate in daily huddles, identify patient needs per protocols, and enhance quality and patient-centered care at Sea Mar.

The role involves coordinating with the care team to fill gaps in care, providing brief interventions, linking patients to behavioral health and

Responsibilities

• 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 resolve them using process improvement strategies.
• Provide brief interventions at point of care to assist patients with management of chronic illness and address social needs.
• Advocate for patient services with community, social service, and medical providers.
• Coordinate care transitions for patients seen in emergency rooms or discharged from hospital/long-term facilities.

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. We are recruiting for the following position:

Sea Mar is a mandatory COVID-19 and flu vaccine organization

Position Summary

This position is responsible for the coordination of care for patients with chronic conditions and behavioral health needs at point of care. As a member of the Clinical Care Team, the Care Coordinator will participate in daily huddles, identify the patient's needs according to protocols, and provide point of care services. The Care Coordinator is responsible for enhancing quality and patient-centered care at Sea Mar Community Health Centers.

Duties and Responsibilities

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 self-worth. Sea Mar is an advocate for its clients and aims to achieve industry-leading, client-centered, culturally aware services.

• 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
• Continually 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.

Patient Care Coordination Job Description

• 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/Health Center Administrator, 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 act