Job Description

The Care Coordinator is responsible for supporting preventive and primary care services for patients by ensuring the deliberate organization and coordination of patient care activities, including facilitating, monitoring and evaluating care transitions, in collaboration with the PCMH team and health center leadership.


Incumbent performs a range of straightforward to moderately complex tasks and exercises some degree of responsibility and judgment related to the patient care transitions. A moderate variation in the work pattern exists. Planning is required regarding work content and choice of work method within general guidelines. The nature of the work provides for self-regulation of routine work. Advice and guidance from the PCMH team and mental health/behavioral health providers is available as needed.

Provide excellent customer service to patients, families, and guests:

Interact with patients and others in a respectful and culturally competent manner. Maintain confidentiality of patient personal, financial, and health records. Ensure patients are identified with two forms of identification (i.e. name, DOB) at each visit and before all procedures. Answer phones calls/respond to messages per policy. Communicate with patients, families, and guests in a professional and courteous manner. Assess for and report potential environmental and patient safety risks. Attend assigned staff meetings and trainings Will attend Outreach Events as scheduled by Supervisor. Utilize interpreters/interpreting line as indicated to ensure effective communication.

Ensure the deliberate organization of patient care activities:

Participate in pre-visit planning and post-visit follow-up care. Assess patient needs for care transitions. Collaborate with the patient and PCMH team to create plan for care transitions. Facilitate arrangements for medical referral provider visits. Assist in linking patients to social/other services for identified needs. Review visit summary/take home instructions/return for follow-up with patients; provide clarification and education as appropriate. Provide follow-up for all referral activities to ensure successful care transitions; work with the patient and referral provider/organization to resolve potential/actual barriers to care. Ensure complete documentation of all referrals in the EHR according to policy. Update referral partner contact information as indicated and ensure changes are communicated with staff and updated in the EHR. Engage in member management/care management activities to address pending care gaps. Assist patients as a connector obtain insurance in the marketplace and work with all uninsured patients obtain appropriate coverage.

Engage in quality improvement activities aimed at optimizing health outcomes:

Ensure standardized care transition related policies and procedures are up to date. Monitor the EHR provider organizer and other related processes to ensure successful care transitions, and provide follow-up as indicated. Identify trends of barriers to successful care transitions and develop plan to address those barriers. Identify gaps in staff knowledge related care transitions and provide appropriate education/reeducation as directed. Work with third party payors to resolve authorization barriers related to care transitions as directed. Work with insurance companies to acquire pre-authorizations for referrals and specialty Assist health center leadership in evaluating referral and tracking processes. Work with managed care organizations related to care gap reports and identify trends for improved outcomes. Serve as a liaison between the health center and medical and social service partners. This includes identifying barriers to care transitions and working with the partner, as directed, to resolve those issues. Propose quality improvement and policy changes that optimize patient care transitions and improve health outcomes. Will be trained and checked off to help in clinic as needed for triage or other clinic duties, including front office check in.

Supports the office functions by completing all other duties and special projects as assigned

Networks and completes professional development activities to enhance knowledge, skills, and abilities. Attends meetings, training, and other events as requested. Offers to assist others in the department to effectively handle workload. Cross-trains others and participates in cross-training to enhance skills. Acts in compliance with contracts, laws, regulations, BCHC policies, procedures and standards. * Completes special projects and other duties as assigned.