Care Coordinator-Bilingual Spanish at TrueCare

Position Summary

The Care Coordinator is responsible for providing comprehensive care management and care coordination for patients who are part of an assigned panel, particularly those with serious, complex, or chronic health problems or psychosocial issues. The Care Coordinator also works in collaboration and continuous partnership with a multidisciplinary care team to achieve optimal outcomes and promote wellness, preventative care and disease management for patients.

Essential Functions

• Collaborate and partner with care team to identify patient treatment goals and barriers to care.
• Educate patients and their families to Patient Centered Medical Home (PCMH) concepts.
• Serve as part of a care team that is a supportive and informational resource for patients, care team and family/caregiver(s).
• Promote and monitor adherence to a care plan, developed in coordination with the care team, patient, and family/caregiver(s).
• Educate patients on treatments, procedures, medications, and continuing care needs.
• Assist in coordinating group visits and other activities, as determined by organization needs and recommendations.
• Connect patients to relevant community resources, with the goal of enhancing patient health and well-being and increasing patient satisfaction.
• Assist patients in navigating care plans (e.g., request interpreters as appropriate, resources for social determinants of health such as transportation services).
• Facilitate patient access to appropriate medical and specialty providers.
• Process referrals for high-risk populations and ensure follow-up, as needed.
• Document pertinent care management information (e.g. plans, interventions, goals).
• Assist with data collection and generation of patient reports.
• Attend in-person case conferences and periodic meetings, as scheduled.
• Participate in quality improvement activities, as assigned.
• Perform other related duties as assigned.

Job Requirements

• High school diploma or equivalent.
• Graduate of an accredited Medical Assistant Program, or at least one (1) year of care coordination experience, or one (1) year of referrals experience.
• One (1) year of medical office experience in an out-patient clinical setting.
• Successful completion of a Team Based Care cohort within 6 months of position start date or as soon as available.
• Bilingual in English and Spanish.
• Knowledge of medical terminology and care coordination.
• Computer proficiency, particularly with Electronic Health/Medical Record systems and the Microsoft Office suite, including Outlook and Word.

CERTIFICATIONS:

Medical Assistant Certificate

Nice to have

• Associates degree in social work, human services, counseling, human relations or related field.
• Two (2) years’ experience in chronic disease management, case management, utilization management, and acute care.

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