The Patient Care Coordinator (PPC) supports designated Primary Care Teams, with an emphasis on chronic disease management and high-risk care coordination. As a co-located member of the Primary Care Team, will oversee the registry of chronic disease patients and activates them to ensure adherence to care pathways. The PCC will be assigned respective duties to Chronic Disease Management or High-Risk Patients, and will work closely with Care Management and Social Work teams.

Duties and Responsibilities:

• Supports patients in meeting their care goals and adhering to their pertinent care plan.
• Conducts telephonic or electronic outreach to patients requiring follow-up on their care plan, in order to ensure continuity of proper care.
• Engages patients in becoming active members in their care plan by applying motivational interviewing techniques.
• Grooms provider schedules to ensure appropriate visit interventions.
• Coordinates and attends patient case conferences with appropriate providers including the care manager and social worker. Attends to any follow-up task emerging from case conferences.
• Updates provider goals and care plans, if needed, to allow for visibility by entire care team.
• Performs pharmacist orders to ensure adherence to pharmacist drug therapy plan, if the patient is enrolled in Drug Therapy Management (DTM).
• Completes care coordination orders for patients as determined by provider, care manager, and social work. Maintains a daily management tracking system.
• Schedules and confirms transportation, home health, DME, and other external vendors including community resources for patients.
• Schedules pertinent provider appointments such as primary care, specialty, procedures, etc.
• Ensures all discharge orders are completed per discharge plan or providers' order in accordance with their care plan.
• Assists in verifying health plan benefits for any ordered services.
• Remains available to assist with visit checkout for patients to ensure all needs are addressed prior to leaving clinic.
• The PCC will be assigned to Chronic Disease Management or High-Risk Patients and will follow an issue process to address non-adherence or any other patient concerns.

High school diploma/GED required.

Three (3) years of professional experience in healthcare required. Three (3) years of previous care coordination and/or managed care experience highly preferred.