PMCH, CMA Patient Care Coordinator (FT) MSMG Int Med - Elizabethton

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Company: Mountain States Health Alliance
Location: Johnson City, TN
Date Posted: January 8, 2015
Source: MiracleWorkers.com
Serves in the Patient Centered Medical Home (PCMH) and works collaboratively with physicians, staff and other health care professionals to provide a medical home and coordinate care across the health care continuum for all patients within the physician office setting.  Position is an integral member of the health care team who works to ensure safety, best practice and high quality standards of care are maintained across the continuum of care.

Responsible for coordinating a wide range of self-management support and disease registry activities for the clinic's entire patient population.  Success will be measured by the results for the process and outcome performance measures of the population of patients in the clinic.  Works closely with the Patient Centered Medical Home and Clinical Deliverable Steering Committees.

ESSENTIAL FUNCTIONS:
Behavior Standards:
*    Demonstrates professional, appropriate, effective and tactful written, verbal, and non-verbal communication with patient, families, medical staff, colleagues, vendors, and other departments ...
Serves in the Patient Centered Medical Home (PCMH) and works collaboratively with physicians, staff and other health care professionals to provide a medical home and coordinate care across the health care continuum for all patients within the physician office setting.  Position is an integral member of the health care team who works to ensure safety, best practice and high quality standards of care are maintained across the continuum of care.

Responsible for coordinating a wide range of self-management support and disease registry activities for the clinic's entire patient population.  Success will be measured by the results for the process and outcome performance measures of the population of patients in the clinic.  Works closely with the Patient Centered Medical Home and Clinical Deliverable Steering Committees.

ESSENTIAL FUNCTIONS:
Behavior Standards:
*    Demonstrates professional, appropriate, effective and tactful written, verbal, and non-verbal communication with patient, families, medical staff, colleagues, vendors, and other departments throughout the continuum of care to promote continuity of care and services and enhance clinic image.
*    Demonstrates positive professional customer service being respectful of all patients, coworkers and providers, treating all with equality regardless of their sex, color, race, medical problem, sexual orientation, religion or socioeconomic status.
*    Demonstrates a positive attitude by smiling and being courteous to all patients, coworkers and providers, making every effort to be non-judgmental with comments and conversation.
*    Acknowledges patient's rights on confidentiality issues, maintains patient confidentiality at all times, and follows HIPAA guidelines and regulations.
*    Participates in orientation and staff development activities as requested.
*    Proactively acts as patient advocate, responding with empathy and respect to resolve patient concerns and recognizes opportunities for improvement through patient concerns.
*    Complies with dress code and strives to act professionally in words and actions at all times.
*    Participates effectively as a team member in the clinic being accountable, helpful and welcoming to co-workers, providers and patients.
*    Proactively continues to educate self to provide quality care and improve professional skills.

Duties Specific to a Patient Care Coordinator
1.    Maintains the disease registry data  including:
a.    Assuring data is kept up to date.
b.    Identifying patients overdue for visits, labs, or referrals and arranging for follow-up services as appropriate.
c.    Identifying patients not meeting clinical goals, such as BP control or glucose control, and arranging for follow-up services by protocol or as appropriate.
d.    Creating patient, physician, and clinic level quality performance reports.

2.    Conducts pre-visit chart review of   patients including but not limited to:
a.    Identification of all needed preventive health maintenance, immunizations, and chronic disease interventions.
b.    When standing orders allow, the diagnostic studies may be ordered or completed before the patient sees a provider.
c.    Managing patient needs using Population Health Management (PHM) Dashboard Reminders for Identified Practice Measures

3.    Works with patients and families on Self-Management Support including:
a.    Setting short and long-term goals for self-management of chronic disease.
b.    Addressing medication adherence in patients not meeting outcome goals.
*    Works with patient to create a plan for Health Behavior Change
*    Assessing and working on the patient's readiness to change, the importance of change, and confidence in ability to change.
*    Helping the patient to identify and overcome barriers
c.    Makes a plan for follow-up between visits
d.    Provides or arranges needed patient education regarding specific health care skills and general disease concepts.
e.    Assist with shared medical appointments.
f.    Communication face-to-face in the office setting, by telephone, or by e-mail.

4.    Coordination of Care across the care continuum including:
a.    Assist as liaison with patients and their families to physicians, clinical staff, and other departments.
b.    Acting as a liaison with hospitalized patients and the clinic.  Following up with patients by phone shortly after hospital and emergency room discharge.
c.    Acting as a liaison with specialty clinics.
d.    Proactively acts as patient advocate, responding to and working to resolve patient concerns
e.    Providing a link to community resources

5.    Involvement in QI activities:
a.    Assesses clinic needs and then collaborates with Clinic Staff, PCMH and Clinical Committees on strategies to achieve individual clinic level goals such as quality and efficiency.
b.    Actively participates/coordinates committees as needed/requested, i.e. performance Improvement Teams.
c.    Communicates and coordinates with the healthcare team in the development of tools for optimal patient outcomes and report findings.

MSHA expects that every team member will role model Patient-Centered Care behaviors and be guided by MSHA's Values and the Principles of Patient-Centered Care. Every member of MSHA's leadership team is accountable for coaching and monitoring reporting team members to ensure that the standards and initiatives of Patient-Centered Care are a living reality in their work units / Departments.

It is vital that an individual in this position be capable of good communication skills. It is of the utmost importance that written communication is legible.


MSHA expects all team members to support the VOS initiative by demonstrating awareness of the VOS system and effectively applying it to his/her work.
Job duties of this position may require access to protected patient information (PHI). The team member will be accountable for appropriate use of the record and compliance with all confidentiality and security policy and procedures related to use, access, and disclosure of PHI.
REPORTING RELATIONSHIP
The Patient Care Coordinator reports directly to the Patient Care Manager; indirectly reports to the Mountain States Medical Group Provider Champion and Site Supervisor of designated practice.



*    CMA Required with Current Licensure
*    Must have 5 years clinical experience and previous and previous data management and/or data abstraction experience.
*    Experience in case management, utilization review and/or quality is preferred.
*    Excellent Computer Skills with Microsoft Office Suite and Electronic Health Records required
*    Excellent communication, problem-solving, critical-thinking, decision-making, time management, organizational and customer service/service recovery skills
*    Knowledgeable of patient care operational processes.
*    Demonstrated ability to work autonomously and collaboratively.
*    CPR Certification Required
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