Accountable Care Organization Coordinator

JOB SUMMARY:
Centered in a clinician provider practice, this individual works in partnership with patients, families, nurses, physicians, and other qualified healthcare providers and clinical disciplines. Coordinates care for patients with chronic disease and manages effective care transitions for them within the continuum. Partners with the provider care team for successful preventative care visits to reduce the severity of chronic disease and avoidable acute illness. Provides effective clinical health coaching to assist patients with self-management of their chronic disease and life-style changes to mitigate health risk. Promotes effective partnerships and utilization of community resources. Facilitates a “shared goal model” within Artesia Healthcare Professionals and across settings to achieve coordinated high-quality care that is patient and family-centered.

ESSENTIAL FUNCTIONS:

• Supports the functions of the ACO Department.
• In collaboration with ACO Director and practice leaders, establishes and maintains an effective internal tracking system for patients such as annual wellness visit scheduling, transition of care follow-up calls/timely provider visits, and CCM monthly encounters.
• Ensures that all required elements are documented for TCM, CCM, and related AWV component billing.
• Coaches patients/caregivers toward successful self-management of their chronic disease.
• Utilizes tools and documents that support a guided care process, collaborates with patient/caregiver toward an effective plan of care.

? Assesses patient and caregiver’s unmet health and social needs.
? Provides effective communications to improve health literacy.
? Develops care plans based on mutual goals with the patient, caregiver, provider, and medical records as appropriate.
? Monitors patient adherence to plan of care and progress toward goals in a timely fashion, and facilitates changes as needed.
? Creates ongoing processes for patient/caregivers to determine and request the level of care coordination support they desire over time.

• Promotes healthy behaviors in all populations and ensures navigation assistance with community resources.
• Facilitates patient access to appropriate medical and specialty providers as well as other care coordination team support specialists.
• Cultivates and supports primary care and subspecialty co-management with timely communication, inquiry, follow-up and integration of information into the care plan regarding transition-in-care and referrals.
• Serves as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources.
• Ensures effective tracking of test results, medication management, and adherence to follow-up appointments.
• Assists providers and other clinic staff with providing high quality care for all patients.
• Facilitates and attends meetings between patient, caregivers, care team, payers, and community resources as needed.
• Attends and actively participates in all Care Coordination related training and meeting activities (Health Coach certification, quarterly Regional Workshops, monthly cohort calls with other Care Coordinators and Caravan Health CC Program Coach) as assigned.

ADDITIONAL RESPONSIBILITIES:

• As assigned

POSITION COMPETENCIES:

• Core Values consistent with a patient/family-centered approach to care.
• Demonstrates professional and effective written and verbal communication skills.
• Demonstrates understanding in use of IT resources and patient databases. Demonstrates a positive, respectful attitude and professional customer service.
• Acknowledges patients’ rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations.
• Proactively acts as a patient advocate, responding with empathy and respect to resolve patient/family concerns.
• Recognizes and responds to opportunities for improvement.
• Demonstrates continual learning skills, effects change in approach to care based on established, evidence-based practice.
• Demonstrates professional practice behavior.
• Assists with mentoring/coaching of other care coordination team members.
• Cultivates effective partnerships, effectively collaborates with all practice providers (Physician, Nurse Practitioner, Physician Assistant and other licensed allied health team-members).

RISK MANAGEMENT/QUALITY MANAGEMENT/SAFETY: Cooperates fully in all Risk Management, Quality Management, and Safety Activities and Investigations.

MINIMUM POSITION QUALIFICATIONS:

• Current licensure as a Licensed Practical Nurse Preferred
• Previous experience in caring for chronic disease patients required.
• Two years experience in provider practice or clinic health setting preferred.
• Strong critical thinking skills.
• Attention to detail and accurate documentation.
• Ability to work in a high volume caseload environment and deal effectively with rapidly changing priorities.
• Effective organizational, leadership, communication, education, collaboration, and counseling skills.
• Previous Care Coordination, Case Management, or Home Health experience preferred.
• Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.
• Ability to speak a relevant second language preferred.
• Previous experience with health IT systems and data reports preferred.
• Demonstrated ability to work constructively with all disciplines related to caring for patients within the community.

ENVIROMENTAL CONDITIONS: Work environment consists of daily patient contact, which may include exposure to blood, or other body fluids.