JOB TITLE: PATIENT CARE COORDINATOR

REPORTS TO: CHIEF CLINICAL OFFICER (CCO)

I. JOB SUMMARY / OVERVIEW

 Connect with patients in the practice, by phone, or in other settings as needed. The

primary focus of the role will be to work closely with the high risk patients to support

them in coordinating their care, addressing barriers, and helping them become more

involved in their health care.

II. PRIMARY DUTIES

Every effort has been made to include all duties; however, the omission of a specific

statement of duties does not exclude the duty from the position if the work is similar, related

or is a logical assignment of the position.

 Conduct comprehensive assessments that include the medical, behavioral, pharmaceutical

and social needs of the patient, identify gaps in care and barriers to attaining improved

health;

 Based on this assessment, and in conjunction with the patient, the patient’s provider, and

other members of the care team, create and implement a care plan that will address the

identified needs, remove the barriers and improve the health of the patient;

 Coordinate care by serving as the advocate and resource for the patient, their family, and

the providers, building effective relationships in the community and across the continuum

of care; (local hospitals, home health agencies, senior community service agencies, etc.)

 Support the patients and family to ensure safe transitions across the continuum of care;

 Assess the patient’s knowledge of their clinical condition and provide education and self-

management support based on the patient’s unique learning style;

 Work with the patient and their caregiver to increase their self-efficacy and ability to play

a central role in their care;

 Measure, improve, and maintain quality outcomes (clinical, financial, and functional) for

individual patients and the population served;

 Work directly with providers and clinic staff to support the ACO projects (Annual

Wellness Visits, Welcome to Medicare Visits, post hospital and emergency room

transition of care calls and scheduling as directed by the CCO) while also identifying

patients for care management interventions.

III. EDUCATION / QUALIFICATIONS

 Must be a licensed Practical Nurse (LPN) or Registered Nurse (RN)

 Employee is responsible for obtaining and maintaining a BLS certification.

IV. EXPERIENCE / KNOWLEDGE / SKILLS

 3-5 years of nursing experience, preferably in care or case management, home health,

ambulatory care, community public health, social work, utilization management, or care

coordination across multiple settings and with multiple providers

 Demonstrate initiative and function independently.

Patient Care Coordinator (PCC)

Revised: 6/1/22 Demonstrate effective communication skills

 Experience in working with an electronic medical record.

 Familiarity with the community we are serving or commitment to learn and understand

through on the ground networking, community assessment, etc.

 Knowledge and experience motivating patients and teaching self-management skills

 Experience working with vulnerable populations (geriatrics, minorities, behavioral

health)

 Ability to navigate ambiguity with the aid of structured problem solving techniques

 Exceptional communication skills, both written and oral, ability to positively influence

others with respect and compassion

 Comfort with facilitating meetings and coaching other staff

 Strong work ethic built on a foundation of proactivity, collaboration, and teamwork

V. PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an

employee to successfully perform the essential functions of this job. Reasonable

accommodations may be made to enable individuals with disabilities to perform the essential

functions.

 While performing the duties of this job, the employee is regularly required to sit, use

hands and fingers, handle and feel objects, reach with the hands and arms, talk and hear.

The employee is required to stand, walk, climb, and occasionally balance, stoop and

kneel. The employee must lift and move 20 pounds or more. Specific vision abilities

required by this job include close vision, distance vision, color vision, peripheral vision,

depth perception and the ability to adjust focus.

 The employee may have exposure to communicable diseases, bodily fluids, toxic

substances, medicinal preparations and other conditions common to a clinic environment.

VI. MISCELLANEOUS

 Accepts and is supportive of change.

 Must possess a high degree of integrity and excellent work ethic.

 Accepts guidance and suggestions for improvement.

 Willing to assist and work with others.

 Maintains strict and total employee and patient confidentiality.

 Complies with PrairieStar Health Center Policy & Procedure.

 Complete all required in-service training and attend all required meetings.