The Care Coordinator is to coordinate team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. Facilitates a "shared goal model" within and across settings to achieve coordinated high-quality care that is patient and family centered.
• Promote the mission, vision, and values of the organization
• Recognizes and responds to opportunities for improvement.
• Provides mentoring/coaching of other population health and care coordination team members and coach patients/families
toward successful self-management of their chronic disease.
• Utilize tools and documents that support a guided care process, collaborate with patients/family toward an effective plan of
o Assess patient and family's unmet health and social needs
o Provide effect communication to improve health literacy.
o Develop a care plan based on mutual goals with patient, family, and provider's emergency plan, medical summary,
and ongoing action plan, as appropriate. Monitor patients adherence to plan of care and progress toward goals in a
timely fashion, facilitate changes as needed.
o Create ongoing processes for patients/families to determine and request the level of care coordination support they
desire over time.
• Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support
specialists (e.g. Diabetes Educator)
• Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow up, and
integration of information into the care plan regarding transitions-in-care and referrals.
• Serve as a point of contact, advocate, and informational resource for patient, family, care team, payers, and community
resources and facilitate and attend meetings between patient, families, care team, payers, and community resources, as needed
• Perform regular visits to provide patient and family support and education
• Collect data and write brief reports to meet evaluation needs of the program.
• Perform other duties as assigned
• Adhere to dress code, appearance is neat and clean.
• Complete annual education requirements.
• Maintain patient confidentiality at all times.
• Report to work on time and as scheduled.
• Wear identification while on duty.
• Maintain regulatory requirements, including all state, federal and local regulations.
• Represent the organization in a positive and professional manner at all times.
• Comply with all organizational policies and standards regarding ethical business practices.
• Communicate the mission, ethics and goals of the organization.
• Participate in performance improvement and continuous quality improvement activities.
• Attend regular staff meetings and in-services.
• Must be a licensed practical or registered nurse in Oregon
• 1-3 years' experience in clinical or community health settings -preferred
• Previous experience in caring for chronic disease patients required.
• Previous Care Coordination, Case Management or Home Health experience a plus
• Experience with navigation of local medical and social support systems a plus
• Previous experience with health systems and data reports-preferred
Knowledge, Skills, and Abilities
• Knowledge of community health services
• Strong organizational and demonstrates the ability to maintain accurate notes and records.
• Strong interpersonal skills
• Ability to demonstrate strong essential leadership, communication, education and collaboration and counseling skills.
• Ability to communicate proficiently through technology (email, cell phone, etc.)
• Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers, as
• Ability to demonstrate continual learning skills, effects changes in approach to care based on established, evidence based
• Ability to determine appropriate course of action in more complex situations
• Ability to work independently, exercise creativity, be attentive to detail, and maintain a positive attitude
• Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work
• Ability to maintain confidentiality of all medical, financial, and legal information
• Ability to complete work assignments accurately and in a timely manner
• Ability to communicate effectively, both orally and in writing
• Ability to handle difficult situations involving patients, physicians, or others in a professional manner
• Negative TB Test
• Current Hepatitis shots
• Social Security Card
• CPR & First aid
• Provide personal and Professional references
• Must be able to speak, read and write English
• No criminal record
• Travel to clients in the Portland metro area
• Must have reliable transportation, valid ID or drivers license.
Please feel free to call or email Elisa anytime!
Principals only. Recruiters, please don't contact this job poster.
do NOT contact us with unsolicited services or offers