Pediatrics Care Coordinator - On Site

Position Summary:
Under the direction of the Pediatrics Program Supervisor, the Pediatric Care Coordinator is part of the primary care practice team and is responsible to assist with coordinating and providing population health services to pediatric patients within the practice who are at most risk for health deterioration or poor outcomes. The Pediatric Care Coordinator's role is to improve health outcomes through scheduling preventative and maintenance care appointments, educating patients, building the medical home between patients and practitioners, and enhancing communication and continuity of care. The Pediatric Care Coordinator uses a culturally-sensitive approach with all patients - in person, by telephone, or web portal. The Pediatric Care Coordinator works with the Care Team to facilitate patient's access to appointments, services, and health care resources, thereby supporting patient's self-care management goals.
Essential Functions of the Job:

• Shares accountability for overall patient health outcomes, working in coordination with Care Teams to discuss progress towards PCMH goals.
  • • Uses evidence based health education and coaching techniques to support and improve patient's self-management and self-efficacy to meet their health goals, including:

• • • a)Setting the agenda
    • b)Ask-Tell-Ask
    • c)Know your numbers
    • d)Action planning
    • e)Medication reconciliation and adherence
    • f)Teach Back (closing the loop)
• Practices culturally and linguistically appropriate team based approaches to meet the individual literacy needs of every patient.
• Ability to work and communicate with people from various ethnic, socio-economic, and educational and experiential backgrounds.
• Maintains an encouraging and flexible approach with patients to support their progress towards meeting their individual action plan and health goals.
• Helps patients identify and find solutions to overcome their specific barriers and limitations in meeting their action plan and health goals.
• Reinforces information given to the patient and/or family with handouts to improve patient self-management skills.
• Documents, revises and updates self-management action plan goals in EHR according to guidelines.
• Documents and updates Care Coordination workbook according to PCMH standards and guidelines.
• Uses i2i program to track, monitor, and generate reports to improve population health outcomes.
• Performs outreach calls to patients based on preventative and chronic disease guidelines.
• Helps to facilitate group health education classes.
• Actively participates and engages in meetings and trainings to improve Care Coordination services and the Patient Centered Medical Home model, provides constructive feedback on the content.
• Functions at highest level of certification and competency.
• Ability and willingness to self-motivate, prioritize, and work independently.
• Actively participates and engages as a member of the multi-disciplinary Care Team.
• Educates and collaborates with Providers, RN's and MA's as needed, related to Care Coordination.
• Works in cooperation with leadership and Care Team on change processes and management to improve effectiveness of Patient Centered Medical Home model of care.
• Promotes teamwork and trust by communicating respectfully and professionally with Care Team, patients, and public.
• Positively impacts patient experience by demonstrating values of Transforming Care including, but not limited to courteous and helpful behavior and a commitment to accuracy.
• Participate in the Clinical Quality Indicators meetings, sharing progress from their patients.
• Create/generate monthly reports and sharing them with care team and Care Coordination team
• Evaluate Patients progress and updating their status on i2i at every follow up
• Update Patient list on PCMH - Workbook at every follow up
• Participate in the Research department meetings
• Present Care Coordination program to the Care team and other departments
• Other duties as assigned.

Additional Duties and Responsibilities
Supports the implementation of the six standards of the patient-centered medical home model of care to promote:

• Patient -Centered Access for both routine and urgent needs of patients/families/caregivers at all times.
• Team-Based Care by providing continuity of care using culturally and linguistically appropriate, team based approaches.
• Population Health Management by supporting evidence based decisions and proactive care reminders based on complete patient information, health assessment and clinical data.
• Care Management and Support through systematically identifying individual patients and their action plans, and manages and coordinates care based on need.
• Care Coordination and Care Transitions within the health center and across specialty care, hospital partners, and other organizations in the community.
• Performance Measurement and Quality Improvement by using data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience.

Job Requirements
Education Required:

• High School Diploma/GED - required

Certifications Required:

• Current Medical Assistant Certificate
• Valid CA Driver's license and insurance
• Other related certifications, i.e., RN, MD (international acceptable) - preferred

Experience and Required Skills:

• Minimum of 2 years of clinical and/or patient care experience as Medical Assistant or higher

Verbal and Written Skills Required to Perform the Job:

• Excellent interpersonal skills.
• Excellent verbal and written communication skills.
• Bilingual: English/Spanish (speaking/writing) - required

Technical Knowledge and Skills Required to Perform the Job:

• Basic computer skills and literacy
• Demonstrate ability to be culturally sensitive and appropriate in working with others.
• Demonstrate respect for diversity.
• Strong attention to detail.
• Outstanding organizational, multi-tasking and problem-solving skills.

Equipment Used:
Computers, phones, copy machines, fax machines, Microsoft Office (Word, Excel, and Outlook); Data Tracking Systems: i2i, NextGen
Working Conditions and Physical Requirements:
Constant sitting, standing, use of personal vehicle to travel to clinic sites and/or meetings.
Universal Requirements
Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs. Compliance with all mandated vaccinations and all boosters is a term and condition of employment.
About Us San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family. The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 108,000 patients through a vast and integrated network of 47 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees. Apply today and become a part of our mission-driven team! San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment. Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.
Other details

• Pay Type Hourly
• Min Hiring Rate $25.26
• Max Hiring Rate $36.01

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