The Care Coordinator is responsible for the completion of clinical and administrative tasks in primary care to ensure that patients receive healthcare that is competent, caring and meets with a high degree of satisfaction. The Care Coordinator at Annex West Health Center is a key linkage resource, coordinating and executing all activities related to the primary care, outreach and HIV care programs. The Care Coordinator interfaces with patients in the programs’ populations of focus (including HIV+ individuals, persons testing for HIV, persons at high-risk and patients with complicated medical needs) and performs a range of administrative duties to optimize program outcomes.
Team members are expected uphold the health center mission by assuring that patients receive health care that is competent, caring, and meets with a high degree of satisfaction. In addition, staff must support FPCN's commitment to the creation of a trauma-informed system of care that continually recognizes and responds to the impact of traumatic stress on all those who have contact with the organization, including children, adults, families, caregivers, and staff.
Act as the liaison between Action Wellness and The Annex West Health Center for both patient and staff inquisitions.
Coordinate all components of primary care, outreach and the HIV and High-risk patient care (e.g., scheduling appointments, performing appointment reminder activities, conducting follow-up calls for no-shows, troubleshooting non-clinical patient issues).
Conduct assessments of patients referred to the programs and develop goals to support healthcare access and treatment. This may include medication reconciliations, medication adherence support, coordination of communication between providers, providing health information, assisting with medical benefits, and other responsibilities as needed.
Provide Hospitalization follow-up and risk assessment for discharged patients
Receive referrals for care management requests from providers, triage needs and coordinate care appropriately
Track referrals to specialty care and for preventive care procedures such as mammogram and colonoscopy to ensure completion
Track laboratory tests to ensure completion
Process prior authorizations as a support to the Medical Assistants
Participate in care management activities in collaboration with the PC team
Utilize direct messaging platforms to send and receive communication between hospitals, specialists, and other providers
Work with Quality Improvement Team to proactively close Gaps in Care, contact patients due for care activities, and manage provider high-risk panels effectively
Provide Front Desk or MA coverage, as appropriate
Establish trusting relationships with patients and communicate concerns to appropriate clinical, social work, or outreach staff as necessary.
Maintain electronic records.
Contribute to AACO reporting needs, including data entry for monthly and quarterly reports.
Implements projects/programs to improve patient satisfaction.
Participate in on/off site meetings and training sessions.
At least 3 + years of experience working as a Medical Assistant, or equivalent experience
Experience working within a community based health center preferred
High School Diploma/GED
Exemplary organizational skills and ability to prioritize
Program management experience a plus
Proficient in MS Office programs and willingness to learn all computer systems needed for success
Education, training, or experience in working with HIV+ individuals and patients with complicated medical needs a plus
Unconditional ability to maintain HIPAA/confidentiality regulations.
Demonstrates cultural competency among persons from various ethnic and social backgrounds.
Family Practice and Counseling Network, a program of Resources for Human Development, is a network of community health centers providing comprehensive primary care, dental and behavioral health services. The Network consists of four health centers in Philadelphia – Abbottsford-Falls Family Practice & Counseling in the Northwest, the Stephen and Sandra Sheller 11th Street Family Health Services of Drexel University in the North, the Health Annex in the Southwest, and Annex West Philly housed in Action Wellness (formerly Action AIDS); and a convenient care clinic in Philadelphia – Fast Family Care. Today the Network serves more than 23,000 patients annually and is an NCQA certified Patient-Centered Medical Home.