Temporary position available in Monroe. Coordinates the monitoring and follow-up of patients requiring ongoing management of their care, with a focus on patients with chronic conditions and/or mental health needs in order to improve patient outcomes and clinic flow.
The Care Coordinator is responsible for being part of the clinical team and enhancing quality and patient-centered care at Sea Mar Community Health Centers. Send letters and perform follow-up phone calls to patients for planned visits. Collaborate with providers in the screening of clients for appropriate level of care through intake assessment.
Provide case management services to identified patients to promote timely, comprehensive, and appropriate care. Advocate for patient services with community, social service, behavioral health, and medical providers.
Facilitate care to those patients who may otherwise fall through the gaps in insurance coverage, medication management, connection to preventive health services, mental health services and/or chronic disease management.
Assist patients with ongoing self-management goal setting based on mutual goal setting and with emphasis on client decision-making. Track patient’s adherence with plan of care in electronic charts. Organize group visits and planned visit events.