Job description

Position Summary:
The Care Team Coordinator serves as a member of the interdisciplinary team, and will provide comprehensive and coordinated care to achieve optimal patient outcomes to meet the Patient-Centered Medical Home accreditation. The Care Team Coordinator assists with the coordination of community health care systems and HMS’ resources to provide culturally and linguistically appropriate services with the goal of providing a seamless model of access and care that benefits the patients and family members based on their individual needs.

POSITION ACCOUNTABILITIES

• Ensures understanding of the Patient-Centered Medical Home (PCMH) model to patients.
• Advocates or facilitates patient access to health care, specialty care or second opinions; assists in coordination of care under the direction of the primary care provider to meet the patient’s goals.
• Identifies the patient’s oral and written communication needs, including the patient’s preferred language for discussing health care with interdisciplinary team.
• As part of the interdisciplinary team, assesses patients for health risk behaviors such as substance abuse issues, tobacco use, and high risk sexual behavior.
• Under the direction of the interdisciplinary team, educates and assists the patient with self-management tools and techniques based on the patient’s planned outcomes.
• Under the direction of the Family Support Director, receives oversight from the Quality Coordinator (RD/CDE) to provide diabetes, and health and wellness education.
• Assists the patient with enrollment services such as Medicaid, Medicare, HMS Sliding Fee, NM Health Insurance Exchange, and other insurance programs.
• Assists patients with enrollment in social service programs such as TANF, SNAP, housing, and other local agency programs.
• As part of the interdisciplinary team, monitors the patient’s progress towards achieving treatment goals.
• Assists the patient’s application process for medication assistance.

• Encourages patients to follow clinical guidelines for care management by, reminding patients of appointments, coordinating non-clinical services and maintains appropriate documentation of patient contact.
• Follows up on patient referrals.
• Reviews Electronic Health Records to assure health needs are met in accordance to clinical guidelines.

Job Type: Full-time

Pay: From $24,057.00 per year

Benefits:

• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Education:

• High school or equivalent (Required)

Work Location: One location

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