San Ysidro Health Center
Care Coordinator (Part-Time)
San Ysidro Health Center, El Cajon, California, United States, 92021
Position Summary:
Under direct supervision of the Care Coordination Supervisor and/or the Program Manager, the Care Coordinator is part of the primary care practice team and is responsible to assist with coordinating and providing population health services to patients within the practice who are at high risk for health deterioration or poor outcomes. The Care Coordinator will also have a role in active research studies (e.g., COVID-19 Vaccination Hesitancy Study), providing support in reporting and implementation, and serve as the liaison between the study and primary care providers.
The Care Coordinator's role is to improve health outcomes through scheduling preventative and maintenance care appointments, educating patients, building the medical home between patients and practitioners, and enhancing communication and continuity of care. The Care Coordinator uses a culturally sensitive approach with all patients - in person, by telephone, or web portal. The Care Coordinator works with the Care Team to facilitate patient's access to appointments, services, and health care resources, thereby supporting patient's self-care management goals.
Essential Functions of the Job: Shares accountability for overall patient health outcomes, working in coordination with Care Teams to discuss progress towards PCMH goals. Uses evidence-based health education and coaching techniques to support and improve patient's self-management and self-efficacy to meet their health goals, including Setting the agenda, Ask-Tell-Ask, Know your numbers, Action planning, Medication reconciliation and adherence, and Teach Back (closing the loop). Practices culturally and linguistically appropriate team-based approaches to meet the individual literacy needs of every patient. Ability to work and communicate with people from various ethnic, socio- economic, and educational and experiential backgrounds. Maintains an encouraging and flexible approach with patients to support their progress towards meeting their individual action plan and health goals. Helps patients identify and find solutions to overcome their specific barriers and limitations in meeting their action plan and health goals. Reinforces information given to the patient and/or family with handouts to improve patient self-management skills. Facilitates the implementation of research programs and evidenced-based interventions to populations of interest. Collects, curates, and organizes data to support research and reporting efforts. Participates in meetings to discuss program outcomes and helps identify program implementation challenges and possible adaptations needed to improve access for the community. Documents, revises and updates self-management action plan goals in EHR according to guidelines. Documents and updates Care Coordination workbook according to PCMH standards and guidelines. Uses Epic to track, monitor, and generate reports to improve population health outcomes. Performs outreach calls to patients based on preventative and chronic disease guidelines. Actively participates and engages in meetings and trainings to improve Care Coordination services and the PCMH model, research studies, and provides constructive feedback on the content. Functions at highest level of certification and competency. Ability and willingness to self-motivate, prioritize, and work independently. Actively participates and engages as a member of the multi-disciplinary Care Team. Educates and collaborates with Providers, RNs and MAs as needed, related to Care Coordination. Works in cooperation with leadership and Care Team on change processes and management to improve effectiveness of PCMH model of care. Promotes teamwork and trust by communicating respectfully and professionally with Care Team, patients, and public. Positively impacts patient experience by demonstrating values of Transforming Care including, but not limited to courteous and helpful behavior and a commitment to accuracy. Participate in the CQI meetings, sharing patient's progress. Create/generate monthly reports and share them with the care team and Care Coordination team. Evaluate patient progress and update their status in Epic at every follow up visit. Update patient list on PCMH - Workbook at every follow up visit. Participate in the Research department meetings. Present Care Coordination program to the Care team and other departments. Provide guidance and ensure patients' access to research studies information, including virtual platforms for educational video modules. Serve as the liaison between research studies and participant's SYH clinic's care team. Provide initial warm handoff to the rest of the integrated care team, Behavioral Health Provider and Social Work. Collaborate in documenting data into the integrated dashboard (Behavioral Health, PCP, Care Coordinator) and use it to share participants progress during team huddles. Provide evidence-based intervention targeting COVID-19 vaccination status. Culturally sensitive approach, targeting Hispanic/Latino, black, and Indigenous patients. Other duties as assigned. Additional Duties and Responsibilities:
Supports the implementation of the six standards of the patient-centered medical home model of care to promote: Patient- Centered Access for both routine and urgent needs of patients/families/caregivers always. Team-Based Care by providing continuity of care using culturally and linguistically appropriate, team-based approaches. Population Health Management by supporting evidence-based decisions and proactive care reminders based on complete patient information, health assessment and clinical data. Care Management and Support through systematically identifying individual patients and their action plans; and manages and coordinates care based on need. Care Coordination and Care Transitions within the health center and across specialty care, hospital partners, and other organizations in the community. Performance Measurement and Quality Improvement by using data to identify opportunities for improvement and acting to improve clinical quality, efficiency and patient experience. Job Requirements
Experience Required:
Minimum of 2 years of clinical experience as MA or higher/equivalent degree with clinical and patient care experience (e.g., RN, MD - both U.S. and international degrees acceptable). Minimum of 2 years working in a healthcare setting using the EPIC electronic health record system. Minimum of 1 year working as a Care Coordinator, with experience navigating a patient's medical chart and providing support in relation to medication adherence, attendance to medical visits, and assisting with linkage to referrals as needed. Experience conducting health research, including recruitment calls, patient interviews, and data collection. Experience educating patients on the following topics: COVID-19, influenza, cervical cytology, breast cancer risks and screening, and colorectal cancer risks and screening. Education Required:
Current MA certificate or higher or equivalent degree. Verbal and Written Skills Required to Perform the Job:
Bilingual English and Arabic. Excellent interpersonal skills. Good written and verbal communication skills. Technical Knowledge and Skills Required to Perform the Job:
Demonstrate ability to be culturally sensitive and appropriate in working with others. Demonstrate respect for diversity. Equipment Used:
Office
( Word, Excel, Outlook), Data tracking system: Epic Working Conditions and Physical Requirements:
Constant sitting and standing Ability to travel between clinic sites and/or meetings.
Universal Requirements:
Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs. Compliance with all mandated vaccinations and all boosters is a term and condition of employment.
About Us San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family. The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 108,000 patients through a vast and integrated network of 47 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees. Apply today and become a part of our mission-driven team! San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment. Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.
Under direct supervision of the Care Coordination Supervisor and/or the Program Manager, the Care Coordinator is part of the primary care practice team and is responsible to assist with coordinating and providing population health services to patients within the practice who are at high risk for health deterioration or poor outcomes. The Care Coordinator will also have a role in active research studies (e.g., COVID-19 Vaccination Hesitancy Study), providing support in reporting and implementation, and serve as the liaison between the study and primary care providers.
The Care Coordinator's role is to improve health outcomes through scheduling preventative and maintenance care appointments, educating patients, building the medical home between patients and practitioners, and enhancing communication and continuity of care. The Care Coordinator uses a culturally sensitive approach with all patients - in person, by telephone, or web portal. The Care Coordinator works with the Care Team to facilitate patient's access to appointments, services, and health care resources, thereby supporting patient's self-care management goals.
Essential Functions of the Job: Shares accountability for overall patient health outcomes, working in coordination with Care Teams to discuss progress towards PCMH goals. Uses evidence-based health education and coaching techniques to support and improve patient's self-management and self-efficacy to meet their health goals, including Setting the agenda, Ask-Tell-Ask, Know your numbers, Action planning, Medication reconciliation and adherence, and Teach Back (closing the loop). Practices culturally and linguistically appropriate team-based approaches to meet the individual literacy needs of every patient. Ability to work and communicate with people from various ethnic, socio- economic, and educational and experiential backgrounds. Maintains an encouraging and flexible approach with patients to support their progress towards meeting their individual action plan and health goals. Helps patients identify and find solutions to overcome their specific barriers and limitations in meeting their action plan and health goals. Reinforces information given to the patient and/or family with handouts to improve patient self-management skills. Facilitates the implementation of research programs and evidenced-based interventions to populations of interest. Collects, curates, and organizes data to support research and reporting efforts. Participates in meetings to discuss program outcomes and helps identify program implementation challenges and possible adaptations needed to improve access for the community. Documents, revises and updates self-management action plan goals in EHR according to guidelines. Documents and updates Care Coordination workbook according to PCMH standards and guidelines. Uses Epic to track, monitor, and generate reports to improve population health outcomes. Performs outreach calls to patients based on preventative and chronic disease guidelines. Actively participates and engages in meetings and trainings to improve Care Coordination services and the PCMH model, research studies, and provides constructive feedback on the content. Functions at highest level of certification and competency. Ability and willingness to self-motivate, prioritize, and work independently. Actively participates and engages as a member of the multi-disciplinary Care Team. Educates and collaborates with Providers, RNs and MAs as needed, related to Care Coordination. Works in cooperation with leadership and Care Team on change processes and management to improve effectiveness of PCMH model of care. Promotes teamwork and trust by communicating respectfully and professionally with Care Team, patients, and public. Positively impacts patient experience by demonstrating values of Transforming Care including, but not limited to courteous and helpful behavior and a commitment to accuracy. Participate in the CQI meetings, sharing patient's progress. Create/generate monthly reports and share them with the care team and Care Coordination team. Evaluate patient progress and update their status in Epic at every follow up visit. Update patient list on PCMH - Workbook at every follow up visit. Participate in the Research department meetings. Present Care Coordination program to the Care team and other departments. Provide guidance and ensure patients' access to research studies information, including virtual platforms for educational video modules. Serve as the liaison between research studies and participant's SYH clinic's care team. Provide initial warm handoff to the rest of the integrated care team, Behavioral Health Provider and Social Work. Collaborate in documenting data into the integrated dashboard (Behavioral Health, PCP, Care Coordinator) and use it to share participants progress during team huddles. Provide evidence-based intervention targeting COVID-19 vaccination status. Culturally sensitive approach, targeting Hispanic/Latino, black, and Indigenous patients. Other duties as assigned. Additional Duties and Responsibilities:
Supports the implementation of the six standards of the patient-centered medical home model of care to promote: Patient- Centered Access for both routine and urgent needs of patients/families/caregivers always. Team-Based Care by providing continuity of care using culturally and linguistically appropriate, team-based approaches. Population Health Management by supporting evidence-based decisions and proactive care reminders based on complete patient information, health assessment and clinical data. Care Management and Support through systematically identifying individual patients and their action plans; and manages and coordinates care based on need. Care Coordination and Care Transitions within the health center and across specialty care, hospital partners, and other organizations in the community. Performance Measurement and Quality Improvement by using data to identify opportunities for improvement and acting to improve clinical quality, efficiency and patient experience. Job Requirements
Experience Required:
Minimum of 2 years of clinical experience as MA or higher/equivalent degree with clinical and patient care experience (e.g., RN, MD - both U.S. and international degrees acceptable). Minimum of 2 years working in a healthcare setting using the EPIC electronic health record system. Minimum of 1 year working as a Care Coordinator, with experience navigating a patient's medical chart and providing support in relation to medication adherence, attendance to medical visits, and assisting with linkage to referrals as needed. Experience conducting health research, including recruitment calls, patient interviews, and data collection. Experience educating patients on the following topics: COVID-19, influenza, cervical cytology, breast cancer risks and screening, and colorectal cancer risks and screening. Education Required:
Current MA certificate or higher or equivalent degree. Verbal and Written Skills Required to Perform the Job:
Bilingual English and Arabic. Excellent interpersonal skills. Good written and verbal communication skills. Technical Knowledge and Skills Required to Perform the Job:
Demonstrate ability to be culturally sensitive and appropriate in working with others. Demonstrate respect for diversity. Equipment Used:
Office
( Word, Excel, Outlook), Data tracking system: Epic Working Conditions and Physical Requirements:
Constant sitting and standing Ability to travel between clinic sites and/or meetings.
Universal Requirements:
Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs. Compliance with all mandated vaccinations and all boosters is a term and condition of employment.
About Us San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family. The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 108,000 patients through a vast and integrated network of 47 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees. Apply today and become a part of our mission-driven team! San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment. Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.