Care Coordinator

Position: Medical Care Coordinator

Who we are:

We are a non-profit health center led by an inclusive team dedicated to improving the health and well-being of the community. Founded in 1920, Eisner Health has grown to provide integrated, culturally competent, and affordable healthcare at multiple locations around the Los Angeles region. Our team works to provide trauma-informed services that address social and medical disparities in order to improve the health of communities and individuals across Los Angeles County.

Position Summary:

In collaboration with the Program Manager, the Medical Care Coordinator supports implementation of the patient’s integrated clinical care plan, working towards resolution of patient’s clinically based needs/barriers. Acts as the patient liaison for the care team. Medical Care Coordinators function as members of the integrated care delivery team. They are responsible for communicating their progress towards resolving patient’s social determinants of health to avoid barriers to their receiving quality care.

Duties and Responsibilities:

  • Performs Health Risk Assessment and initiates plans for eliminating social determinants of health identified in the clinically based assessments.
  • Provide medical coordination assistance for patients referred to/from providers, Care Managers, and from any other provider.
  • Schedule medical and specialty appointments. Provide reminder phone calls for appointments and/or follow-up calls post appointment.
  • Participates in Patient-Centered team meetings aimed at improving patient outcomes or operational processes.
  • Participates in clinical cross care team meetings.
  • Supports implementation of the patient’s integrated clinical care plan, working towards resolution of patient’s clinically based needs/barriers.
  • Maintains timely and appropriate documentation on patient interactions in the EHR, Care Management applications and databases, as directed.
  • Provide important updates to the primary care provider and Care Managers regarding patient progress towards clinically based self-care management.
  • Provide culturally appropriate support and information for patients and their families through follow-up phone calls and make reminder calls.
  • Assist patients with adherence to existing clinical self-management goals or development of new goals.
  • Works with each patient closely to ensure they are meeting the goals set for in their care management plans.
  • Coordinates continuity of patient care with internal and external healthcare organizations and facilities, coordinates information and care requirements with other care providers
  • Ensures timely follow-up with provider post hospitalization/emergency room visit; retrieve discharge summaries and copies of medical records.
  • Complete home and facility visits, if necessary, to ensure patients are following their plan of care.
  • Assists with maintenance and dissemination of the chronic care model to all appropriate Clinic staff.
  • Pursues new and more efficient ways to provide excellent patient and staff experiences.
  • Provides disease specific and preventative care patient education.
  • Serves as liaison between frontline clinic staff and clinicians or other appropriate clinic staff.
  • Performs population management activities as assigned.
  • Requires on-site work three to five days per week, depending on assignments.

Qualifications:

  • Experience working with pediatric patients and families is required
  • Bachelor’s or Associate degree in health or social services or at least 2 years of experience in a clinical setting.
  • Proficient computer skills, including Microsoft Office (specifically Word and Excel).
  • Knowledge of EHR required and ability to enter data.
  • Experience with HIE and population health platforms preferred.
  • Self-disciplined, energetic, passionate, and innovative. Demonstrates ability and desire to relate to and work with people of all ages, social and ethnic backgrounds and to convey a sense of confidence and trust to all patients.
  • Highly organized and well-developed oral and written communication skills
  • Able to maintain confidentiality with all aspects of information in accordance with practice, State and Federal regulations.
  • Ability to assist in the facilitation and coordination of patient care plans.
  • Background in health education and experience is preferred.
  • Covid-19 vaccination requirement as a condition of employment when required by State law. Medical and religious exemptions may apply.

Benefits:

  • Generous Paid Time Off benefit (23 days accrued per year).
  • 9 Paid Holidays.
  • Medical insurance, PPO & zero deductible HMO options available.
  • Low-cost dental & vision insurance.
  • Opportunity for professional leadership training.
  • Opportunities for loan repayment.
  • 403b plan with employer contribution at 3%.
  • License renewal and professional membership reimbursement.
  • CME Time (5 days per year) and Tuition Reimbursement ($1,000 per year).
  • Employer-Sponsored life insurance & long-term disability.

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