Care Coordinator I

• Participate in morning huddles to anticipate the patient’s clinical, social and behavioral health needs.
• Work with the care team to identify gaps in care and work to resolve them using process improvement strategies.
• Advocate for patient services with community, social service, and medical providers.
• Participate and coordinate care transitions for patients who have been seen in an emergency room and/or have been discharged from a hospital/long-term care facility.
• Track patient’s adherence with plan of care in electronic or paper charts and communicate outcomes and recommendations to the primary care provider.
• Organize monthly Health Home meetings by working with the Clinic Operations Team/Clinic Manager, create the agenda and help facilitate the meeting.
• Collaborate with clinical care team to improve Patient-Centered Medical Home processes and provide documentation demonstrating performance.
• Review the medical record for quality and utilization indicators according to the Quality Improvement Plan.
• Train new clinic staff on the Chronic Care Model and Patient-Centered Medical Home.

• Must be able to work independently, prioritize workload, and meet deadlines.
• Must have critical thinking skills and maintain confidentiality.
• Excellent organizational skills and ability to handle a variety of tasks simultaneously.
• Knowledge of medical terminology and/or behavioral health topics.
• Strong decision making and prioritization skills.
• Ability to work respectfully and professionally with the community, patients, families and staff.
• Able to work effectively in a multi-cultural environment with a diverse population.
• Sympathetic, mature, responsible, and reliable.
• Strong patient engagement, interpersonal, and communication skills and ability to establish a therapeutic relationship with the patient.

• Knowledge of the Patient-Centered Medical Home Model and motivational interviewing skills a plus.
• Knowledge of evidence-based standards of care for chronic conditions and behavioral health issues.
• Knowledge of and proficient in Microsoft Word, Excel, PowerPoint, and Outlook.
• Ability to utilize and document relevant patient information the Electronic Health Record.
• Knowledge of community resources.
• Ability to work in a fast-paced community health care setting.
• Ability to think analytically and problem solve in a multidisciplinary team and independently.
• Ability to deal effectively with difficult people and situations.
• Ability to communicate effectively with diverse communities.
• Ability to manage time effectively and prioritize tasks.
• Ability to analyze patient care data.
• Ability to identify client learning needs and to assess client's knowledge, skill level and readiness for learning.
• Ability to maintain the privacy and security of sensitive and confidential information in all formats including verbal, written and electronic; and adhere to policies and procedures related to local, state, and federal privacy requirements.
• Excellent communication and customer service skills.
• Critical thinking skills.
• Ability to understand and implement process improvement activities.
• Bilingual in Spanish is strongly preferred. Other language skills may be considered depending on site needs due to the population that is being served.

• Medical Assistant Training with one or more years of experience in a community health setting or family practice, or, one or more years of equivalent experience. Current licensure is not required for this position.
• This position must obtain CPR within 90 days of hire date and is required to maintain current CPR throughout employment.
• NCQA (National Committee for Quality Assurance) Certification is a plus.
• Valid WA State Driver’s License and proof of liability insurance.

• Medical
• Dental
• Vision
• Prescription coverage
• Life Insurance
• Long Term Disability
• EAP (Employee Assistance Program)
• Paid-time-off starting at 24 days per year + 10 paid Holidays.

Sea Mar Community Health Centers