High Intensity Care - Care Coordinator

Job Description

Job DescriptionJob Summary:
At MyCare Medical, we strive to make sure our patients receive the highest quality, most cost-effective care. We have a dedicated High-Intensity Care (HIC) team supporting our patients, giving them the time that they need to care for each patient and ensure a comfortable and patient-centric experience. The High Intensity Care - Care Coordinator (CC), under medical supervision, assists the High Intensity Care (HIC) Provider in the delivery of health care services.

Job Responsibilities:
Access to care:

• HIC Care Coordinator ensures patients are seen at least once per month and as necessary by HIC PCP and team.
• Outreaches HIC patients to engage them with HIC program based on acuity.
• Schedules PCP HIC visits and ensure adherence with scheduled appointments.
• Answers calls and messages from HIC patients during business hours using dedicated cell phone and office phone.
• Adheres to the process for adding a HIC visit during the day for urgent symptoms, destabilization, and transitions of care.
• Coordinates virtual visit capabilities when available and clinically appropriate, and when patients can use technology.

DURING THE HIC VISIT:

• Obtains patient vitals, and assist Provider with minor procedures, injections (therapeutic/immunization), phlebotomy, collects appropriate consents prior and during visit.
• Educates patients on “Call us first”.
• Captures quality care gaps, screenings, and recommended care for primary, secondary, and tertiary preventions should be addressed and closed on all patients.
• Assist in obtaining Advanced Care Planning and DNR documents.
• Other tasks as assigned.

BETWEEN HIC VISITS:

• Coordination of care between HIC visits.
• Coordination of labs, DME, home health, home infusion, dialysis program, HEDIS measures, and referrals and supports hospice referrals.
• Coordinate integrated collaborative, embedded behavioral health and SDOH (TBD) (use current Health Plans BH/SDOH when available).
• Retrieve every specialty consult note. Referral must be approved by the HIC PCP in coordination with assigned PCP (if/as needed).
• Assist HIC Provider in communicating with hospitalist/SNF team when patient is referred to ED, admitted to the hospital/SNF, and discharge from ED/Hospital, SNF.
• Assist/coordinate HIC APP (TBD) to visits HIC patients at home as indicated by HIC provider.
• Participate with HIC team in regularly schedules huddles/case conferences to review all/some patients at least once a week.
• Verify patient eligibility and appointment confirmation before every HIC appointment.
• Do wellness check in calls with patients every week.
• Assist to dispatch MyCare at Home as needed.
• Assist in obtaining hospital records and scheduling transition of care management visits.

Job Qualifications:

• Medical Assistant Certificate issued by an accredited institution OR
  • One (1) year of experience working in a health care setting that includes direct patient contact OR
  • A combination of training, education, and experience that is equivalent to one of the employment standards listed above and provides the required knowledge and abilities.
• Bilingual in English/Spanish preferred but not required
• Electronic Medical Record (EMR) experience, eCW
• A strong grasp of medical terminology, preferably with geriatric patients; Basic arithmetic.
• Experience in collecting blood samples for 1-year, geriatric population preferred.
• Experience in accurate and efficient taking of vitals in a primary care setting for 1 year.
• Able to speak and communicate clearly, empathetically, and effectively over the phone, in writing and in-person.
• CPR and Basic Life support certification, preferred.
• Ability to respond effectively and collaboratively to unexpected situations.
• Self driven and able to multi-task within a busy office setting.

BENEFITS

• Comprehensive benefits package, including Health, Vision, Dental, and Life insurances
  • FSA and Life Assistance Program (EAP)
  • 401(k) Retirement Plan
  • Health Advocacy, Travel Assistance, and My Secure Advantage
• PTO Accrual and Holidays

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