General Definition and Scope of Job
The Clinical Care Coordinator will play a key role in assisting patients achieve improved health outcomes. Reporting to the Quality Manager , and working closely with the five RN/Care Managers, Community Health Workers(CHWs), the Clinical Care Coordinator will reach out to those patients who need preventive care as well as patients who have chronic diseases. He/she will also reach out to those patients recently discharged from hospital, and who regularly visit the emergency room, to actively encourage them to receive the necessary follow up care, so that Manet can assist patients manage their health more effectively.

Minimum Skills, Experience and Educational Requirements
1. Professional Qualification as a Medical Assistant, Nursing, or LPN preferred;
2. Minimum of 3 years’ experience, a plus;
3. Excellent organizational and interpersonal skills required;
4. Proven customer service skills required;
5. Proven verbal and written communication skills;
6. Highly organized and systematic skills with excellent attention to detail required;
7. Judgment to review the record for ambiguities and/or contradictory material;
8. Must have working knowledge of computers and office procedures;
9. Must have data entry experience;
10. Previous administrative experience strongly preferred; and,
11. Previous experience in a health care setting preferred.

Required Certifications and Licenses

Core Responsibilities
1. Identify sub populations of high risk patients to engage them in proactive care and provide care reminders;
2. Provide appropriate patient education materials to reinforce the need for Routine Preventive Healthcare Maintenance (RHCM) and timely chronic care follow-up;
3. Read ED follow up notes to determine the range of patient needs and subsequently follow up with patients after ED visits and hospital discharge and schedule follow up appointment with preferred provider;
4. Read and review hospital notes for appropriate follow-up and medication reconciliations;
5. Refer to Manet RN care manager, or even embedded Complex Care Manager as needed to determine short and long term care needs;
6. Outreach to patients overdue for appointments and patients who cancelled appointments or DNKA;
7. Use registries insurance reports for example MBHP, PCC, BMC Health Net Community Alliance/ACO, commercial plans including BCBS, Tufts, Harvard as well as Athena EMR reports to identify patients overdue for Routine Preventive Healthcare Maintenance (RHCM) measures and evidence based chronic disease care measures;
8. Provide patient navigation for RHCM measures, for example, mammograms;
9. Outreach to patients who are overdue for care using letters, telephone or email;
Review HMO insurance eligibility lists to identify new patients.
10. Outreach to new patients.
11. Research medical home of inactive patients using insurance eligibility, medical record reviews, and other means. Outreach to patient as appropriate to make appointment with PCP or work with plan and patient to change PCP with plan; and,
12. Any other duties as required.

Critical Demands of the Job
1. Manage multiple requests and prioritize appropriately.
2. Ability to function in a fast paced setting with a variety of patients and staff.
3. Attention to details and prompt follow up.
4. Includes walking and standing for long periods of time, sitting for short periods of time, hand dexterity, clear hearing and speaking ability. Must be able to lift a maximum of 1/3 of their body weight.
5. Excellent organizational and interpersonal skills.

Working Conditions
1. Works in well-lighted environment with comfortable surroundings.
2. Stressful at times due to competing demands, including attention to multiple patients and staff.

Required Availability
May be required to work a rotating schedule as the department requires. This includes evenings, holidays and weekends.