Ma Care Coordinator - Pleasanton, Ca

The Care Coordinator is an integral member of the overall Circle of Care (CoC) Team delivering preventative, holistic care to patients with chronic kidney disease and kidney failure. Working under the direction and delegation of their RN Care Manager dyad partner, the Care Coordinator supports focused, high quality, coordination activities across the continuum of care. These coordination activities include, but are not limited to, transition of care support, panel management, appointment scheduling, hospital and community referrals, addressing gaps in care, health coaching, and support of various care campaigns.   

Responsibilities include: 

• Collaborates with the RN Care Manager and clinical team to build relationships and manage a patient panel. Obtains, reviews, and screens patient lists for prioritization of proactive outreach and necessity of interventions.   
• Provides transition of care management for emergency room visits, hospital discharges, and skilled nursing/acute rehab transitions as required.   
• Maintains timely, consistent, and professional written and verbal communication with all patients, providers, and members of the interdisciplinary care team. Utilizes warm handovers, as indicated.  
• Reviews patient data and pertinent reports, identifies and closes gaps in care, including preventative care, vaccines, overdue diagnostic procedures and labs, co-morbid care gaps, and applicable screenings.  
• Collaborates with practice-based care team to deliver campaigns to patients within Value-Based Care.  
• Schedules urgent appointments and referrals to applicable hospital and community resources.  
• Ensures appropriate cadence of routine nephrology, specialty, and primary care. Contacts patients who miss appointments, are overdue for services and/or need follow-up care based on risk assessment.  
• Works in partnership with the RN Care Manager for patients that are off-track for an optimal dialysis start. 
• Collects and updates elements of the patient's past medical, surgical, social, and family history. Ensures documentation of depression screening and patient activation measures.  
• Utilizes standard documentation and communication tools, such as standard messaging, workflows, and templates, to ensure consistent and accurate communication and health record documentation.  
• Collaborates with RN Care Manager to conduct detailed medication review for applicable patients.  
• Facilitates pre-visit planning, pre-visit labs and advanced access to care (same day appointments).  
• Collaborates with nephrologist and other specialists in delivering and coordinating necessary care/services. 
• Acts as a patient advocate, liaison, and information resource; escalates all critical information to the RN Care Manager in a timely manner. 
• Ensures active participation in daily huddles to review the schedule, anticipate needs, ensure access to all necessary documents, identify and manage care gap registries, and build culture of teamwork, communication, and trust.  
• Monitors and updates plan of care, as applicable.    
• Provides culturally appropriate, structured education about chronic diseases, self-care management (diet, exercise, smoking-cessation, etc.), and applicable health coaching under the direction of the RN Care Manager.  
• Answers inbound patient calls and utilizes warm handover for urgent requests.  Manages and responds to patients' voicemails and messages.  
• Respond to tasks and touchpoints and returns patient calls, as applicable.  
• Adheres to established confidentiality, productivity, and quality standards.  
• Coordinates incoming and outgoing information and performs other administrative tasks to support the team.  
• Performs a majority of work time in-office with patients, providers, and other staff. 
• Facilitate projects and presentations designed to develop and improve the role of the Care Coordinator in the value- based care programs. 
• Act as resource and representative for value-based care at health fairs and professional seminars as assigned. 
• Assists with coverage for PTO and open positions as requested. 
• Serves as a preceptor when assigned. 
• Perform other duties and responsibilities as required, assigned, or requested. 

Qualifications: 

• High School Diploma or equivalent required. 
• Medical Assistant degree, diploma, or certificate. 
• Medical Assistant with minimum of two years' experience within a healthcare related organization (e.g. health system, hospital, clinic, provider practice, health insurance company, etc.) required. 
• Requires medical records experience/exposure. 
• Broad understanding of physician front- and back- office practices, preferably in nephrology. 
• Knowledge of medical terminology. 
• Ability to navigate and document within multiple electronic health records, health-related databases, and other care-related platforms.  
• Knowledge of HIPAA regulations. 
• Knowledge of insurance carriers, copays, and eligibility verification. 
• Knowledge of EHR/EMR systems. 
• Requires working knowledge of Microsoft Office Suite. 
• Highly organized with ability to keep accurate notes and records. 
• Strong interpersonal skills. 
• Telephonic customer service experience preferred. 
• Possess strong time management skills. 
• Detail oriented, professional attitude, and reliable. 
• Ability to interact with internal and external customers in a professional manner. 
• Ability to manage multiple priorities successfully and drive results. 
• Ability to communicate effectively both verbally and in writing. 
• Ability to work independently and with a team. 
• Ability to manage multiple patients simultaneously. 
• Bilingual preferred in certain markets. 

Benefits: 

• Health Insurance 
• Dental insurance 
• Vision insurance 
• Life insurance 
• Disability insurance 
• Paid time off 
• 401K 

The Company is committed to the principles of equal employment. We are committed to complying with all federal, state, and local laws providing equal employment opportunities, and all other employment laws and regulations. It is our intent to maintain a work environment which is free of harassment, discrimination, or retaliation because of age, race, color, national origin, ancestry, religion, sex, pregnancy (including childbirth, lactation and related medical conditions), physical or mental disability, genetic information (including testing and characteristics), veteran status, uniformed servicemember status, or any other status protected by federal, state, or local laws. The company is dedicated to the fulfillment of this policy in regard to all aspects of employment, including but not limited to recruiting, hiring, placement, transfer, training, promotion, rates of pay, and other compensation, termination, and all other terms, conditions, and privileges of employment