INTRODUCTION

Under the supervision of the Health Center Director, the Patient Care Coordinator (OB/GYN) is responsible for the recruitment of, outreach to and the navigation and coordination of services for vulnerable patients living with complex health needs. The position serves as an integral member of an inter-professional care management team working alongside medical providers, nurse care managers and social service staff to meet the needs of our patients. The position performs outreach and navigation services in a variety of Washington, DC settings, including the hospital, primary care clinics, patient homes, homeless shelters, and various other community settings.

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 track 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.
• Identify 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 inter-professional 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.
• With Support from nursing and social service staff, completes activities that helps inform the patient-centered care plan.
• Adheres to Unity’s HIPAA guidelines and ensures the appropriate handling of sensitive information.
• Performs other duties as assigned within the scope of position expectations.

OB/GYN Specific Duties:

• Responsible for the follow-up, outreach to, navigation and coordination of services for pregnant patients.
• Serves as an integral member of OB/GYN team working alongside medical providers, nurse care managers and social service staff to meet the needs of our pregnant patients.
• Performa outreach and navigation services in a variety of Washington, DC settings, including the hospital, primary care clinics, patient homes, homeless shelters, and various other community settings.
• Schedules women who have +UPTs to get them into care within the first trimester with the appropriate provider.
• Assists with scheduling and following-up on ultrasound appointments or reports.
• Assists with scheduling psychotherapy appointments
• Assists with calling and scheduling appointments for pregnant women who are lost-to-care (LTC), non-compliant, or are very high risk (i.e. HIV+).
• Tracks patients from all sites who have consented for Makena services.
• Maintains a list of all pregnant patients at each site with their EDDs and monitor to make sure patients have the appropriate return and postpartum follow up scheduled.
• Makes sure the newborns return for care.
• Coordinate care for surgical patients including scheduling, pre and post op appointment scheduling, faxing records and authorizations to the hospital, obtaining and scanning path reports and dictations, working with billing to make sure authorization and billing are completed.
• Maintain and track an abnormal pap list following the ASCCP guidelines
• Assist with scheduling patients for ultrasounds/imaging and referrals to GYN-Oncology

MINIMUM QUALIFICATIONS

• High school diploma or GED. College coursework in business or health-related field is preferred.
• 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.

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES

• Familiarity with community health, discharge planning, chronic disease management
• Exceptional interpersonal and organizational skills, with attention to detail required; strong oral/written communication skills are a must.
• 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.
• Must have the ability to analyze data.
• Demonstrated proficiency with business software (i.e., Microsoft Office Suite, EMR).
• Requires the ability to travel to multiple office locations.

SUPERVISORY CONTROLS

The position reports directly to the Health Center Director in conjunction with the Nurse Manager.