Coordinator - Care Management

Legacy Community Health is a premium, Federally Qualified Health Center (FQHC) that provides comprehensive care to community members regardless of their ability to pay. Our goal is to treat the entire patient while improving their overall wellness and quality of life, in addition to providing free pregnancy tests, HIV/AIDS screening. At Legacy, we empower patients to lead better lives by promoting healthy behaviors and offering resources such as literacy classes, family planning services, and nutrition and weight management information.

Our roots began in 1981 as the Montrose Clinic, with specialization in HIV education, testing, and treatment. Since then, the agency has expanded to >50 clinics in Houston, one in Baytown, two in Beaumont, and one in Deer Park with extensive services that include: Adult primary care, HIV/AIDS care, pediatrics, OB/GYN and maternity, dental, vision and behavioral health. We also service students within KIPP and YES Prep schools. Legacy is committed to driving healthy change in our communities.

Job Description

The Care Management Coordinator are responsible for conducting telephonic outreach to patients who have discharged from an Emergency Room (ER) setting. During telephonic outreach, the MA screens for unmet health concerns, escalates urgent patient concerns to the appropriate Care team member, provides education regarding alternatives to ER usage, addresses SDOH needs and coordinates a follow up visit with the patients Primary Care Provider or Behavior Health Provider. The Care Management Coordinator is also responsible for supporting the Care Management Team by conducting patient outreach to potential/enrolled care management patients to complete health screenings and Care Team follow up calls as indicated

Essential Functions

* Performs telephonic outreach within one (1) business day of notification to patients who have recently discharged from an Emergency Room setting.
* Screens discharged patients to identify and document any unmet physical, psycho-social and/or behavioral needs.
* Escalates urgent issues to the Care Team RN or Behavioral Health (BH) Social Worker as indicated.
* Coordinates a follow up appointment with the patients Primary Care Team or BH Provider to occur within 7 days of discharge.
* Assesses and resolves transportation needs.
* Provides education regarding alternatives to Emergency Room utilization, including the provision of Legacys After-Hours Nurse Line.
* Educates the patient/caregiver of signs & symptoms to report to the Nurse or Provider.
* Provides education regarding community resources.
* Helps to facilitate the delivery of medications as needed.
* Ensures the timely start of care of prescribed services such as home health and/or durable medical equipment (DME).
* Assists patients with scheduling other medical/specialist appointments as needed.
* Refers members who have ongoing physical, social determinants of health (SDOH) and/or BH needs to the care management team for follow-up.
* Refers patients who have excessive Emergency Room visits to care manager or immediate supervisor for evaluation.
* Utilizes various modalities to communicate with the patient, including phone, text messages and/or other Legacy communication systems.
* Responsible for following up with discharged ER and hospital visit patients who were no shows for follow up appointment. Assist patient with re-scheduling appointments with appropriate provider.
* Maintains required medical documentation of activities within the designated system.
* Follows standards of work and consistently maintains department established timeframes for case completion.
* Escalates quality and patient safety concerns to the Manager or Care Team RN.
* Participates in the refinement and/or development of new standards of work.
* Maintains awareness of key performance indicators/metrics and manages caseloads through coordinating interventions to prevent avoidable ER visits, hospital admissions and readmissions.
* Attend staff meetings and education offerings both in person and via teleconference/online as required.
* All other duties as assigned.

Required Education, Certifications, Licenses, & Training (minimum requirements)

* High School Diploma or equivalent
* Must maintain BLS/CPR

Required Years of Experience (minimum requirements)

* 3-5 years clinic experience
* Familiarity with medical terminology
* Experience educating patients and families regarding self-management
* MS-Office, including Outlook, Excel and Word

Required Knowledge, Skills, and/or Abilities (minimum requirements)

* Experience with all patient populations, including, Commercial, Medicaid & Medicare
* Computer literacy: Ability to operate computer programs and work within various documentation platforms
* This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management
* Strong customer service skills to coordinate service delivery including proactive identification and resolution of issues that will promote positive patient outcomes
* This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management

Desirable Knowledge, Skills, and/or Abilities

* Federally Qualified Health Clinic (FQHC) experience
* Bilingual (Spanish)
* Ability to think critically and problem solve
* Ability to meet Legacy Community Healths EPIC proficiency requirements.

Benefits

As part of values that Healthcare is a Right and not a Privilege, we offer a suite of benefits

* Medical / Vision / Dental (Costs of benefits are based on your yearly salary)
* Medical visit copays are waived when seeing a Legacy provider.

* 9 Holiday + 1 Floating Holiday
* 403b Retirement Plan
* Bright Horizons Back-up Care
* As a user of Bright Horizons Back-Up Care, you can conveniently schedule care right from your mobile device with the Back-Up Care app your easy, time-saving solution to managing family care challenges while on the go.

* Paid Time Off (PTO)
* PTO Exchange benefit

PTO Exchange will provide you with the option to convert a portion of your accrued but unused PTO hours for use toward several different benefits and causes, based on your own priorities.

With PTO Exchange, you can convert a portion of your unused PTO into:

* 403(b) Retirement contributions
* Student loan payments / Tuition for the employee
* Leave Sharing donations to fellow employees