Collaborative Care Coordinator 

SUMMARY: Integrated, comprehensive primary care is increasingly focused on prevention, continuity, education and health maintenance. At our Collaborative Care Health Center, we are partnering with our Primary Care Providers (PCP) in an integrative, collaborative approach to serve patients who struggle with complex conditions, varying diagnoses, chronic and acute pain, behavioral/mood disorders, muscular-skeletal problems, and other complex health challenges, including opioid dependence/substance use disorder issues. The ideal candidate will have direct patient care experience, a passion for whole person care, and interest in how transdisciplinary wrap around services can improve health outcomes.

The Collaborative Care Coordinator (CCC) is part of an innovative, whole person, comprehensive and integrative care team. This position will work within a multidisciplinary team (MDT), made up of a variety of clinical and behavioral health care team staff.

ESSENTIAL DUTIES AND RESPONSIBILITIES: These essential responsibilities are performed within the context of collaboration and coordination with ODCHC’s clinicians, support staff and across multiple ODCHC departments and clinics.

• Work closely within a MDT team and assist the panel through implementation and facilitation of supportive courses for patients in self-management, health education, coaching, motivational interviewing, case conferencing, and care navigation.
• Serve as part of the care team supporting a panel of patients, particularly those with ongoing complex chronic health conditions, as a way of streamlining and enhancing the care experience.
• In partnership with the Program Manager, help champion group medical visits, working within the MDT to determine the needs of the patient population, the appropriate criteria to participate in groups.
• In partnership with Program Manager, help develop course structure and workflows, and help identify the challenges at the clinic and the resources available to make the group visit successful and sustainable.
• Assist with the planning, staffing, implementation and complex /chronic conditions and all group medical visits at our Collaborative Care Health Center.
• Provide patient education under the direction of the provider around goal setting and action planning related to self-care and disease management within MA Scope of Practice; follows-up on treatment plans of panel patients, including clinical recommendations, referrals, medications and self-management activities; schedules follow-up appointments as needed; reaches out to patients between visits to monitor and encourage health maintenance and self-care activities.
• Work to build relationships with all MDT members, helping to support and understand basic tenants of integrative care modalities.
• Contributes positively to the efficiency, accessibility, productivity, quality, safety, compassion, and professionalism of the work setting.
• Coordinate communication and interactions between patient, MDT provider, ancillary services, consultants and primary care providers.
• Ability to assist with direct patient care as outlined in Scope of Practice for Certified Medical Assistant.
• Other duties and responsibilities as identified and assigned by supervisor.

QUALIFICATIONS AND EXPECTATIONS: the successful candidate will possess experience and skills spanning a variety areas:

• Strong interpersonal skills and the ability to establish constructive professional working relationships among a diverse workforce.
• Ability and desire to work in team environment; ability to promote effective communication between patient and practitioner as well as other members of the MDT health care team and clinic; demonstrates superior customer service focus and skills.
• Ability and desire to help patients understand follow-up instructions, patient information handouts, prevention activities and self-management activities; and to clarify details to patients to support their care plan
• Strong knowledge of the California Medical Assistant Scope of Practice.
• Knowledge of the physical examination process and ability to accurately record examination details; ability to document pertinent information from providers and patients; versed in medical terminology.
• Strong computer skills with specific aptitude in Microsoft Office Suite and/or Electronic Medical Records (EMR).
• Organizational skills with focus on tracking patient care and improving patient experiences; knowledge of ODCHC referral process and follow-up; knowledge of routine radiology, laboratory tests, and common CPT codes.
• Knowledge of legal and ethical issues related to health care.
• Knowledge of health care delivery and administration.
• Knowledge of ODCHC clinic operations, patient flow, and documentation needs.
• Knowledge of ODCHC mission, health care delivery and clinical support staff roles and responsibilities.
• Ability to handle difficult or confrontational situations in a calm, consistent and equitable manner.
• Bi-lingual in Spanish or Hmong preferred
• Strong interest in integrative comprehensive whole person care; group visit knowledge.
• Ability to effectively represent ODCHC’s interests in the community and maintain effective working relationships among coworkers, public, private, and professional groups.
• Adhere to ODCHC’s policies and procedures.

EDUCATION AND EXPEREINCE:

• At least 2 years of experience working in a direct patient care role in a medical setting.
• Minimum of 18 months of employment in an applicable position within ODCHC.
• Health Coach Training/Experience preferred. Opportunity for on the job training.

CERTIFICATES, LICENSES, AND SKILLS:

• Certification or Credentialed as a Medical Assistant by an accredited certifying body.
• Injection certification.
• CPR and/or BLS certification.
• Venipuncture certification (preferred).

SUPERVISORY RESPONSIBILITIES: None.

SUPERVISION AND SUPPORT: The Collaborative Care Coordinator reports to the Program Manager and Back Office Manager. An integral part of the health care team, collaborating with and working to meet the needs of providers, behavioral health clinicians, other care coordinators, medical assistants, and other ODCHC both in the clinic and in other clinics and departments.

PHYSICAL REQUIREMENTS: The physical requirements described are representative of those needed to successfully perform the essential duties of the position. Reasonable accommodation will be made to allow otherwise qualified candidates to perform these functions.

• Ability to communicate via telephone, video, and/or in-person.
• Vision adequate to read documents, computer screens, forms.
• Ability to remain stationary for extended periods of time.
• Ability to lift, carry, or otherwise move up to 25 pounds.
• Ability to use keyboard and view computer screens for extended periods of time.
• Ability to travel locally and long-distance.
• Ability to move around offices and clinics as needed.

To search for an open position, please go to http://OpenDoorCommunityHealthCenters.appone.com