JOB TITLE: Site Program Coordinator-My Health GPS (I, II)

FLSA: Non-Exempt

REPORTS TO: Health Center Director

INTRODUCTION

Under the supervision of the Health Center Director, the Site Program Coordinator provides care coordination and patient navigation activities for patients enrolled in the My Health GPS program which seeks to improve health outcomes for complex, vulnerable patients and their families. The Site Program Coordinator will perform monthly touches to ensure adherence to patient and provider goals in the care plans and participate in care coordination activities for all identified patients. The Site Program Coordinator will insure the patient remains connected to care and has a transition of care appointment when needed as they move from the primary care settings to other settings including the hospital, specialty care offices, patient homes, homeless shelters, and various other community settings.

MAJOR DUTIES/ESSENTIAL FUNCTIONS

Essential and other important responsibilities and duties of Site Program Coordinator I may include, but are not limited to the following:

• Partners with site leadership to ensure successful implementation and oversight of MHGPS activities including patient enrollment, follow-up and follow-thru
• Supports protocols and work flows to enhance the six core activities of DCHF's My Health GPS: comprehensive care management, care coordination, health promotion, comprehensive transitional care from inpatient to other settings, individual and family support services, and referral to community and social support services.
• Utilizes CRISP report and other tools available to provides outreach to those patients discharged from the hospital to ensure there is a HOSPERFUP visit scheduled within one business week with primary care provider or a member of their care team.
• Participates in outreach to those patients who are attributed to Unity Health Care, Inc. but are not enrolled to provide education to the patient about the MHGPS program to foster ongoing enrollment in the program as assigned by Program leadership.
• Performs touches as determined by Department of Health Care Finance guidelines to assure compliance in the program and ensure the patient is progressing with goals as assigned by providers and nursing staff. The Site Program Coordinator will document the progress and touch in the chart according to established guidelines for the program
• Performs ongoing Quality Assurance to maintain data integrity as it relates to record keeping and clinical documentation.
• Manage own panel of at-risk patients not being followed by care teams to include but not limited to: patients recently hospitalized, patients who have been lost to care and patients needing intensive care coordination services.
• Provides patient navigation services and interventions on behalf of patient and their families to reduce barriers in receiving care outside of Unity to hospital, provider offices and community services.
• Assists health center leadership in planning and executing interprofessional case conferences, team meetings and care management rounds.
• Acts as a liaison between hospitals, primary care providers, specialists, community resources and Managed Care Organizations on behalf of enrolled patients to ensure patient-centered care coordination.
• Monitors site-based MHGPS activities and provides guidance and support related to all care coordination and care management activities.
• Refers and connects patients to Case Management services as needed to reduce barriers due to social determinants of health.
• Attends relevant training as necessary to maintain professional certification and/or knowledge.
• 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.

SITE PROGRAM COORDINATOR II Additional Duties:

The Site Program Coordinator II shares all the duties of the SPC1 with the additional responsibility of performing annual care plan updates as indicated by Program leadership for those patients who are continuing on in the program.

MINIMUM QUALIFICATIONS

• Site Program Coordinator I requires a high school diploma or equivalency.
• Site Program Coordinator II requires a bachelor's degree and a minimum of 40 hours of demonstrated care management experience and training.

Additional qualifications of I and II include:

• Work experience in Community Health, Public Health or Social Work OR an equivalent combination of education and experience which provides the required knowledge, skills and abilities deemed sufficient to prepare the applicant to successfully perform the duties of the position.
• One (1) year of demonstrated leadership abilities in a clinical setting.
• Two (2) years of experience providing care coordination or case management services; experience in a hospital and/or community/outpatient setting.
• Experience working with at-risk populations in a role such as: Care Coordinator, Patient Navigator, Community Health Worker, or Case Manager etc. is preferred.

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES

• Must be able to demonstrate the ability to create site-based reports, track progress and communicate needs to health center leadership
• Demonstrated ability to communicate and drive outcomes across professional disciplines, organizations and clinical settings especially on behalf of medically and socially vulnerable populations.
• Must understand network of servicing providers across Washington, DC metro area (to include other FQHCs, acute care hospitals, specialists, etc.).
• Must have a working knowledge and understanding of medical terminology
• Ability to utilize health information systems, including: EMRs; data reporting and disease surveillance registries; health information exchanges; prescription drug monitoring platforms; and population health management platforms.
• Ability to work collaboratively in a team and manage multiple priorities, utilize effective time management skills, and exercise sound professional judgment.
• Demonstrated ability to work well with people of various ages, backgrounds, ethnicities, and life experiences.
• Requires the ability to travel to multiple office locations.
• Exceptional interpersonal and organizational skills, with attention to detail required; strong oral/written communication skills are a must.
• The ability to work at a computer and analyze data.
• Exceptional computer skills (i.e., Microsoft Office Suite, eCW), especially with MS Excel and the PHM module in eCW.

SUPERVISORY CONTROLS

This position reports directly to the Health Center Director.

GUIDELINES

The position abides by all rules and regulations set forth by applicable licensing and regulatory bodies, as well as UHC policies and procedures.

PERSONAL CONTACTS

PERSONAL CONTACTS The position requires contact with staff at all levels throughout the organization. There are also external organization relationships that may be part of the work of this individual.

PHYSICAL EFFORT AND WORK ENVIRONMENT

• Must be physically able to sit, stand, and walk for long periods of time. Must be able to bend, lift, and carry files from one location to another.
• Must have visual acuity and the ability to differentiate colors, and sustain long periods of computer usage.
• May sit for prolonged periods of time at a desk or in an automobile and/or may use the telephone for long periods of time.
• The office environment may be stressful with multiple, time-sensitive tasks to be accomplished within a short period of time.
• Must be able to work any time of the day, independently with minimal supervision, be capable of making sound business decisions, be detail oriented, alert, and self-motivated.
• Must be able to effectively manage difficult situations, staff, and customers.
• Please refer to the attached ADA Checklist

RISKS

The position involves everyday risk and discomforts, which require normal safety pre-cautions typical of such places as offices, meetings, training rooms, and other UHC health Care Sites. The work area is adequately lit, heated, and ventilated. All medical services shall be provided according to medically accepted community standards of care. The employee shall provide evidence of recent (within the past twelve (12) months) health assessment that includes a PPD and/or chest x-ray results.

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.