Coordinator Planned Care
Cambridge Health Alliance - Somerville, MA

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The Planned Care Coordinator (PCC) will work closely with the Primary Care Practice Leadership Team to support team-cased care using the Team Based Care Guidelines and Planned Care Model. Reporting to the practice’s Nurse Manager, the PCC will perform a range of functions which safely, effectively, and efficiently support the patient care teams. 1. Assumes day to day responsibilities for coordinating care teams at designated Primary Care Sites. 2. Initiates contact with patients as needed, working proactively with the site leadership team to insure access to health care services by identifying and removing barriers to care. 3. Accesses, prepares, and shares quality metrics and associated patient outreach lists regularly with care teams. 4. Prepares quality reports, through chart review and other data sources, in advance of care team meetings in order to ensure accurate and prioritized patient outreach lists. 5. Uses the Primary Care Empanelment Guidelines to maintain accurate patient panels. 6. Documents all patient encounters in a timely manner using appropriate Epic tools. 7. Trains new providers and staff in Planned Care model and use of Epic in relation to the quality reports and associated patient lists, and also performs on going training as needed. 8. Participates in department meetings, including practice All Staff meetings and Ambulatory Planned Care Coordinators/Nurse Managers meeting. 9. Reviews monthly quality reports and associated patient lists for accuracy, and communicates with Ambulatory Quality staff when errors are identified. 10. Shares best practices within Primary Practices that the PCC supports and also across Ambulatory sites. 11. Delegates the patient outreach work in and outside of care team meetings, and works with Nurse Manager and other site leaders to ensure accountability for the work. 12. Identifies the unique needs and implement appropriate interventions for the Age-specific categories circled below: Neonate Pediatric Adolescent Adult (18-59) Geriatric (60 +) 13. Integrates growth and development needs into the delivery of patient care for the populations served. 14. Uses communication methods appropriate for the patient developmental stage. 15. Accurately assesses the patients ability to follow directions for completion of treatment. 16. Identifies and manages any special issues, concerns and risks for age-specific populations. 17. Performs other duties as assigned by supervisor High energy individual with excellent interpersonal, organizational, and computer skills. Effectively interacts with all members of the health care team and with patients. Maintains confidentiality around patient issues. Takes initiative to proactively organize and manage the responsibilities of the job. Language: Bilingual (English and Portuguese or Creole or Spanish) in the specific cultural/language group of the population/community served. Education/Training: Bachelors degree, preferably in human services or a related field required. Licensure: N/A. Work Experience: Two years in a relevant human service field in a multi-disciplinary setting; experience with relevant community groups and/or in a multicultural setting preferred.
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