Chronic Care Coordinator I at NORTHERN COUNTIES HEALTH CARE INC – Island Pond, Vermont

Job Summary:

A Chronic Care Coordinator I provides comprehensive support and guidance to patients with chronic illnesses, ensuring they receive appropriate care and resources to manage their conditions effectively. They act as a central point of contact, coordinating care between patients, healthcare providers, and community resources. The role involves developing and implementing personalized care plans, monitoring patient progress, and facilitating communication to improve patient outcomes.

Supervisory Responsibilities:

This position has no direct supervisory responsibilities.

Essential Job Functions/Responsibilities:

• Provides patient-centered, basic, short-term case management for medically and/or socially complex patients as below:
  • Meets with patients for face-to-face and/or telephone contacts in order to facilitate success with self-management goals.
  • Assesses patient for goals of care and barriers to care.
  • Follows up with patients and pharmacies to be sure patients are filling and taking their medications as prescribed.
  • Tracks and follows up on referrals to diagnostic testing, specialists, and health education (diabetes educators, dietitians, asthma educators, etc.), and to behavioral health specialists or other behavioral health providers.
  • Proactively follows up with Health Center patients who have received inpatient or Emergency Department services at local hospitals, in accordance with Health Center protocols. This involves ensuring a seamless transition of care by coordinating with hospital staff, scheduling follow-up appointments, and addressing any additional needs the patients may have.
  • Connects patients to support services as needed both externally and internally as a Health and Wellness resource.
  • Reminds patients of appointments and collects information prior to appointments.
  • Follows up with providers and patients to schedule patients for medical care per Health Center protocols.
  • Provides patient/ family education and instruction on issues of health maintenance and management of chronic conditions, provides patients/ families with educational materials for self-management in a manner most appropriate to their learning.
• Coordinates patient care with external disease management and/or care management organizations.
• Is an active member of the Community Health Team (CHT), helping to coordinate care for people with complex or chronic conditions.
• Works closely with Department of Vermont Health Access (DVHA) for patients who are served by both the Health Center and DVHA.
• Performs outreach and care management duties for patients who are considered high risk or very high risk by the Accountable Care Organization.
• Interacts and collaborates with multiple agencies to formulate and document shared care plans with and for patients.
• Facilitates team based care by being a bridge between the patient, the practice and the community. This may include coordinating and facilitating Care-Team Meetings.
• Assists in defining site-level protocol to identify patients who may benefit from care management based on criteria such as:
  • Behavioral health conditions.
  • High cost/high utilization.
  • Poorly controlled or complex conditions.
  • Social determinants of health.
  • Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff, patient/family/caregiver
• For patients identified for care management, consistently uses patient information and collaborates with patients/families/caregivers to develop a documented care plan that addresses barriers and incorporates patient preferences and lifestyle goals documented in the patient’s chart.
• Participates in Health Center panel management and Population Health Initiatives
• Assists in identifying and providing outreach to patients who are due or overdue for appointments, lab tests, eye examinations, chronic condition procedures, etc. per health center protocol.
• Reviews panel reports regularly.
• Works with the Quality Team and IT department to ensure accuracy of data.
• Is an active member of the Health Center Quality Improvement (QI) and Leadership teams at the practice level, and is included in treatment planning for patients.
• Meets regularly with the Clinical Practice Manager to prioritize care coordination needs for the practice.
• Uses clinical, operational and demographic data and information to identify areas for improvement.
• Assists in monitoring office processes to identify areas for improvement; recommends areas for improvement to the Health Center QI and Leadership teams, and assists in monitoring improvement initiatives within the office.
• Provides information to the Health Center about resources, collaboratives, educational opportunities and initiatives that support the Health Center.
• Completes all EMR and other documentation as required.

It is expected that you will meet the productivity standards that are set forth by your Supervisor and/or NCHC Division protocols.

The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description

Position Qualifications:

• Education/Licensure: LPN, MA, EMT, LCSW, LCHMC. Provider level CPR/BLS required
• Experience: At least two years of experience in a health care or human services related field. Experience in primary care office, designing and implementing healthcare quality- improvement initiatives preferred.
• Knowledge and Ability: Must maintain a high level of confidentiality. Must have proficiency in computer skills including, but not limited to email functions, spreadsheets, document processing, and Electronic Medical Records, as well as the ability to multitask, respond to shifting priorities, and to work well under pressure while meeting all required deadlines. Ability to work independently while demonstrating the skill to work positively within the framework of a team

Typical Physical Demands

Requires prolonged sitting, some bending, stooping, and stretching. Requires eye- hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator, and other office equipment. Requires normal range of hearing and eyesight to record, prepare, and communicate appropriately. May require occasional lifting up to 25 pounds.

Standards of Conduct

Each employee is responsible for conducting themselves in an ethical manner, and reporting possible violations through the appropriate channels. Employees must be careful in both words and conduct to avoid placing or appearing to place pressure on subordinates or coworkers that could cause them to violate these standards of conduct or to deviate from accepted norms of ethical business practice.