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Form of workJob Description
HEARTLAND HEALTH CENTERS is now TAPESTRY 360 HEALTH!
Summary: The Integrated Care Coordinator (ICC) is the link between patients, Tapestry 360 Health, other health care services, and community-based organizations. The ICC will work alongside patients, assessing patient needs for improved health, reducing barriers to health care access, and working to close gaps in clinical care, with an aim toward improving patient health outcomes at the individual and population health levels. Furthermore, the Clinical Integration Coordinator partners with patients to provide disease-specific health education and connects patients with resources for unmet social needs.
Essential Duties and Responsibilities:
- Provides peer support and advocacy for patients navigating the health care system and builds relationships with patient, family and other individuals, as well as health care team staff and community organizations.
- Assesses health risk and patient needs for patient population, and connects patients to resources for unmet social needs
- Communicates with patients regarding scheduled appointments and follow-up visits. Assists patients in obtaining primary care, specialty care and ancillary services. Reports identified health care challenges to their manager.
- Enrolls eligible patients in disease management program(s) and provides disease-specific and preventive care patient education according to program requirements.
- Monitors patients (in person or by telephone) at required frequencies and tracks clinical outcomes as indicated (i.e. PHQ-9, blood pressure, HbA1c).
- Regularly collaborates, coordinates, and communicates with clinical care team members to resolve outstanding patient care related items, better facilitate care delivery, and facilitate treatment plan changes in consultation with the PCP. This includes preparing for and participating in regularly scheduled caseload oversight with clinical staff (behavioral health, nursing, or medical professional) as applicable.
- Enters and maintains electronic medical records, compiles reports and completes other program documentation.
- Facilitates transitions of care for patient, including between specialty and inpatient/outpatient settings. When required, obtains medical records from other organizations involved in patient care (I.e. hospital and ER discharge records, specialty notes, and/or imaging).
- Supports population health and quality improvement efforts, including conducting outreach and education to targeted populations of patients to close care gaps.
- Other duties may be assigned.
Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Required Education and/or Experience:
- A minimum of two years of healthcare or public health experience is required.
- Experience with electronic medical record systems and Microsoft Office is required.
- High school diploma or GED Required
Preferred Education and/or Experience:
- Associate’s or bachelor’s degree is preferred.
Benefits offered to Tap360 full-time employees:
Choice of 4 BCBS Medical Plans | Choice of 2 BCBS Dental plans | BCBS Vision Plan | BCBS Life, AD&D, Short- & Long-Term Disability Insurance | 401K | 11 Paid Holidays | Generous PTO including Sick Leave, Vacation and Flexible Days
