The Patient Care Coordinator (HSP) works to ensure that pediatric patients and families receive services in regards to positive parenting, Early Intervention services, maternal mental health services and resource assistance in relation to housing, childcare, employment, early care resources, food and additional needs that may arise.

Under the supervision of the Health Center Director, the Patient Care Coordinator-Healthy Steps Program (HSP) is responsible for providing comprehensive care coordination for pediatric patients (ages 0-3) and families. The s Patient Care Coordinator (HSP) will perform outreach, navigation of services and work closely with the HealthySteps team, particularly the HealthySteps Specialists.

MAJOR DUTIES/ESSENTIAL FUNCTIONS

Essential and other important responsibilities and duties may include, but are not limited to the following:

• Utilizes strength-based patient-centered motivational interviewing techniques to build rapport and help patients improve their health
• Participates in the development, maintenance, and adjustment of individualized care plans for high-risk patients that address both medical and social barriers to accessing care.
• Acts as a professional liaison between hospitals, primary care providers, specialists, community resources and Managed Care Organizations on behalf of patients to ensure patient-centered care coordination.
• Identifies and tracks special populations including high-risk patients and other populations due for preventive or chronic care services.
• Helps patients obtain the care they want and need, when they need it, which may include: assistance with financial/insurance options, solutions for transportation and translation services, , and/or removal or resolution of other barriers to care.
• Identifies and track patients discharged from the inpatient service or the emergency department
• Utilizes team-based communication strategies to close the loop on referrals, hospital follow-ups and any outstanding items identified in the patient's care plan.
• Supports the primary care team by providing panel management to decrease the number of patients lost to care, non-compliant in follow up care and disconnected from primary care.
• Performs outreach activities in primary care sites, homes, hospitals, and neighborhoods.
• Identifies which appointments may be made for patients before leaving the clinic and strive to coordinate care before they leave (e.g., mammogram and/or specialists)
• Identifies opportunities to close gaps in care
• Works with interprofessional team members to identify barriers to care with the goal of finding solutions and resources to remove the barriers to care.
• Assists patients with navigating the healthcare system including but not limited to working with pharmacies, social service agencies, and insurance agencies as well as internal services such as the lab and other discharge processes
• Participates in interdisciplinary case conferences and team meetings.
• Provides culturally appropriate health education
• Provides cultural mediation between communities and health and human needs
• Communicates patient-related needs to appropriate clinical staff including those on the patients care team as well as those providing care coordination and care management services.
• Acts as liaison between patient and Primary Care Medical Home in resolution of problems or referral of appropriate resource
• Completes activities that helps inform the patient-centered care plan with Support from nursing and social service staff.
• Adheres to Unity's HIPAA guidelines and ensures the appropriate handling of sensitive information.
• Performs other duties as assigned.

HealthySteps Program (HSP) Specific Duties:

• Collaborates with HS Specialists through the monitoring/tracking of patient data utilizing the Montefiore Tool.
• Performs patient outreach for missed appointments and schedules patients for follow-up appointments
• Conducts a weekly review of HS Specialists clinical schedule; to address patient needs prior to appointments and consults with HS Specialists around patient/families' needs through working with/connecting them to external organizations that work with patients ages 0-3.
• Collaborates with HS Specialists, medical providers, nurse managers and ancillary staff.
• Responsible for timely submission and follow-up of Early Intervention, Mental Health and Early Care Referrals for pediatric patients.
• Collaborates and communicates with the OB/GYN, Pediatrics and Social Services Departments on Care Coordination.
• Contributes to the improvement and enhancement of the HealthySteps model by attending HSP Team meetings, professional development and organizational wide trainings.

MINIMUM QUALIFICATIONS

• High school diploma or GED. College coursework in business or health-related field is preferred.
• Minimum of two (2) years of experience providing care coordination service. Experience in a hospital and/or community/outpatient setting is preferred.
• Experience working as a part of an inter-professional team.
• Familiarity with community health, public health programming, pediatric patient population.

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED BY THE POSITION

• Exceptional interpersonal and organizational skills, with attention to detail required; strong oral/written communication skills are a must.
• Exceptional computer skills (i.e., Microsoft Office Suite, EMR).
• Ability to work collaboratively in a team and manage multiple priorities, utilizes effective time management skills, and exercise sound professional judgment.
• Demonstrated ability to work well with people of various ages, backgrounds, ethnicities, and life experiences.
• Proven ability to work collaboratively and productively with clinicians, administrators, patients, and other individuals from various backgrounds and skill sets.
• Requires the ability to travel to multiple office locations.

The statements contained herein describe the scope of the responsibility and essential functions of this position, but should not be considered an all-inclusive listing of work requirements. Individuals may perform other duties as assigned including work in other areas to cover absences or relief to equalize peak work periods or otherwise balance the workload.