Care Coordinator III

The Care Coordinator – Panel will report to the Care Coordinator of PCMH and Lean. Panel management, at Clinica Sierra Vista (CSV), allows primary care physicians to use dedicated time to direct proactive care for their patients, uses staff support to conduct outreach, and leverages new panel-based information technology tools.

Essential Functions:

• Meet with all new patients, explaining PCP’s, Patient Portal and all aspects to accessing care.
• Assign patients to provider panels ensuring balance.
• Receives monthly panel report and reviews PCP assignments.
• Determines continuity percentages for each provider – assure that majority of visits with PCP
• Monitors influx of new patients into provider panels and analyzes provider capacity to absorb new patients; reviews issue with Medical Director and reassigns as appropriate.
• Assesses panel size against ideal panel size and discusses any needed adjustments with Medical Director and/or management team.
• Resolves unassigned patients by reviewing appointment history (and possibly the clinical record) to determine appropriate assignment.
• Tracks patient status changes including death, transfer to other care, and makes the change in the practice management system.
• Responsible for patient transfers within and outside CSV for the assigned PCP’s.
• Collaborates with Panel Manager at appropriate site.
• Patient-initiated PCP-change requests; facilitates discussion between and obtains approval from current assigned PCP and future PCP; makes the change in the practice management system.
• Provider-initiated PCP change requests. Facilitates discussion between current PCP and potential future PCPs; obtains agreement of acceptance by the new PCP.
• Makes the change in the practice management system.
• Patient transferring care to non-CSV provider: Facilitate communication with outside provider to ensure continuity.
• Proactively engage priority patients to promote availability of expanded access clinic and reduce unnecessary Emergency Room utilization.

Quality Manager:

• Ensure CSV planned visits are scheduled and followed up (Medicare annual visits, PT/INR, chronic disease, annual health checks, etc.).
• Run, manage and analyze standard CSV reports.
• Identify needs and uses for custom reports and communicate the desired results to manager.
• Oversee and analyze data from assigned panels in regard to CSV-priority conditions. This includes the running of reports within the CSV computer structure, Excel etc.
• Quality improvement coach for site & responsible for documenting biweekly quality meetings using CSV meeting minutes template.
• Identify, coordinate, document and track quality improvement projects (PDSA) that align with CSV priorities.
• Responsible for clinic-wide compliance with CSV, PCMH, CMS, Meaningful Use and California Department of Public Health (CDPH) requirements.
• Clinic-wide required to meet or show consistent improvement on CSV clinical quality goals.
• Develop and implement planned care for patient panels: huddles, pre-visit planning, recalls, follow ups.

Care & Communication Coordination:

• Act as liaison/bridge between patient, call center, clinic operations and clinical teams.
• Analyze (and manage, where appropriate) patient care contacts (i.e. visits, phone calls, web encounters, complaints, variances, incidents, etc.) to determine trends, gaps and process improvement.
• Analyze and manage patient show reports (i.e. no shows, patient left without being seen, cancellation, reschedule, etc.).
• Responsible for ensuring that staff follow-through on all CSV-priority visits, recalls and orders.
• Manage and analyze high-risk patients including emergency department/hospitalization follow-ups, medications, recalls, referrals and orders, etc.

Other Responsibilities:

• Responsible for ensuring all clinical staff are trained to the CSV Way.
• Compliance with all applicable laws, rules, regulations and CSV policies is a condition of continued employment. Cooperation with the Clinica Sierra Vista corporate compliance program is a condition of employment.
• Other duties as assigned.
• Data analysis skills. Knowledge of clinic operations (in order to interpret and validate data findings).
• Must have working knowledge of all clinic operations (clinical and operational) to facilitate transitions of care for patients.

Qualifications:

• Education: Medical Assistant or equivalent years in health care
• Computer proficiency: Excel, Word, Outlook, EPIC, PDF, etc.
• Spanish speaking preferred
• Maintain excellent internal and external customer service at all times.
• Maintain the highest degree of confidentiality possible when performing the functions of this department.
• Possess the tact necessary to deal effectively with patients, providers, and employees, while maintaining confidentiality.
• Must be able to work independently, handling high volume and multiple tasks.
• Must be reliable with attendance.
• Must be highly organized and detail oriented.
• Possess knowledge of modern office equipment, systems and procedures.
• Ability to multi-task and work efficiently in a potentially stressful environment.
• Ability to apply common sense understanding when carrying out detailed written or oral instructions.
• Must have excellent verbal and written communication skills.
• Ability to effectively present information and respond to questions from internal and external customers.
• Must have a pleasant, professional attitude toward patients, providers, co-workers and superiors.
• Teamwork skills a must.
• All other duties as assigned by the Care Coordinator of PCMH and Lean.

Physical Requirements:

• Bending/Twisting 5%
• Walking 15%
• Sitting 40%
• Push/Pulling 5%
• Reaching Overhead 5%
• Driving 5%
• Standing 5%
• Repetitive Motion 20% (keyboard)
• Must be able to lift up to 25lbs

Clinica Sierra Vista values human rights, goodwill, respect, inclusivity, equality, and recognizes that the organization derives its strength from a rich diversity of thoughts, ideas, and contributions. As leaders in healthcare industry, we aspire to be an employer of choice by promoting an organizational culture that reflects these core values. We seek to attract, develop, and retain a talented and dedicated workforce where people of diverse races, genders, religions, cultures, political affiliations and lifestyles thrive. Our goal is to create a welcoming and inclusive environment that empowers our employees to provide the highest level of service to our community of residents and businesses; they’re counting on us.

Clinica Sierra Vista is an equal opportunity employer and strives to attract qualified applicants from all walks of life without regard to race, color, ethnicity, religion, national origin, age, sex, sexual orientation, gender identity, gender expression, marital status, ancestry, physical disability, mental disability, medical condition, genetic information, military and veteran status, or any other status protected under federal, state and/or local law. We aim to create an environment that celebrates and embraces the diversity of our workforce. We welcome you to join our team!