Medical Home Care Coordinator (LPN or MA)

# Positions
Job Status
Regular Full-Time
13311 N 56th St

Job Description

Medical Home Care Coordinator

Department:              Family Practice Temple Terrace

Position Level:           6B

Reports to:                 Officer Supervisor/Manager

Job Summary:           Medical Home Care Coordinator is responsible for facilitating care coordination services for patients in need of enhanced care coordination services. Eligible patients will be ensured that they will receive timely, high quality, and efficient health care and support services through the development of a multi-disciplinary care plan, self-management goals and referrals to both internal and external resources.


Essential Functions of the Position:

Patient Navigator & Care Coordination

  • Be the system navigator and point of contact for patients and families, with patients and families having direct access for asking questions and raising concerns
  • Track and support patients when they obtain services outside the practice such as; Emergency Departments, Hospitals, and other health care facilities. This includes obtaining medical records from facilities and other health care providers.
  • Follow-up with patients within a few days of an emergency room visit or hospital discharge Under the direction of the practitioners, communicate test results, and care plans to patients/families
  • Assist patients in problem solving potential issues related to the health care system, financial or social barriers (e.g., request interpreters as appropriate, transportation services or prescription assistance)
  • Working collaboratively with other team members, provide care management services for high risk patients
  • Track and document all calls received afterhours via the office answering service into the patients electronic health record
  • Document and Import all DOC Halo messages received from providers into the patients electronic health record

Care Planning

  • Provide relevant self-management support for patients with chronic illnesses as identified by clinical teams
  • Collaborate with other members of Medical Home for care coordination and care management activities including implementation of Care Plan
  • Manage referrals, when needed, to appropriate agencies required to assist the client in achieving the goals and objectives identified in their Care Plan
  • Work with patients both in person and over the phone to remind and review their plan of care and progress towards their goals

Community Liaison

  • Identify and utilize cultural and community resources
  • Identify and link patients with community resources to facilitate referrals and respond to social service needs
  • Assist patients with the process of determining eligibility, obtaining and maintaining free pharmaceuticals through the Patient Assistance Program
  • Act as a liaison between the Clinical Transformation Team and Medical Home

Data Collection

  • Assist with data collection and generation of patient registry reports
  • Assist with data collection and generation for PCMH recognition and renewal
  • Ensure timely documentation in Electronic Health Records
  • Participate in Performance Improvement/Continuous Quality Improvement activities, as assigned

Additional Responsibilities:

  • Ensures all members of the care team are up to date on clinical competencies
  • Provides excellent customer service to his/her team, patients, and public
  • Maintains an organized and clean work area
  • Performs other incidental and related duties as required and assigned
  • Attends all meetings required by office manager/supervisor physician, hospitals, or Director/Associate Director


Physical and Mental Demands:

  • Normal physical ability
  • Above average concentration and high level complexity of decision making
  • High level verbal and written communication skills
  • Above average ability to manage multiple tasks simultaneously
  • High tolerance to stressful situations

Occupational Exposure:

  • High risk exposure to bloodborne pathogens and chemical hazards


Job Qualifications:

  • LPN or Certified MA with a minimum of 36 months of experience in health care setting
  • Strong written and verbal communication skills
  • Teamwork orientation
  • Able to take and follow through with delegated tasks and accountability
  • Resourcefulness in problem solving
  • Proven data analysis skills
  • Proven organizational skills
  • Beginner to intermediate proficiency in Microsoft applications: Excel, Word, Outlook, PowerPoint
  • Ability to demonstrate excellent customer service and strong cultural competency
  • Ability to adhere to strict confidentiality guidelines








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