Care Coordinator Social Determinates of Health
Niagara Falls Memorial Medical Center is in growth mode and looking for a Case Coordinator to join our Primary Care team. This position provides care coordination and care management to patients of the NFMMC Primary Care Network. The position works in collaboration with family members, caregivers, physicians, other health and mental health providers and community-based programs. ESSENTIAL FUNCTIONS: I. In concert with primary care patients, develops care plans that set forth patient goals and objectives, describes action strategies to help meet patients' objectives, identifies medical and community-based resources to address identified patient needs, and refers patients to the appropriate service entities. 2. Develops and updates care plans at a patient's primary care appointment or telephonically. 3. As part of care coordination functions, screens patients for eligibility for direct and support services and refers patients to needed medical, mental health and social services. 4. Uses knowledge and expertise to coordinate community service utilization, provide ongoing review of plans of care, and assist the transition of care from one setting to another. 5. Performs ongoing and continuous follow-up review of high risk, high utilizing primary care cases to ensure the appropriate treatment plan is followed to meet patients' medical, mental, physical, and/or social needs. 6. Maintains documentation of all care plans and revisions thereto as well as all patient encounters in the patient's electronic medical record. 7. Works with primary care providers and others to identify community-based resources that can be made available to patients. 8. Initiates outreach and missed appointment procedures, as necessary. 9. Oversees the flow of care plans that have been prepared by NFMMC departments, including but not limited to the Outpatient Behavioral Health Clinic and the Health Home to the appropriate primary care patients' electronic medical records. 10. Becomes well-versed and plays an active role in the Primary Care Department's Social Determinants of Health (SDoH) program, including use of the AHC assessment tool, scoring AHC assessment results, making community-based referrals through the use of an electronic platform, and tracking such referrals. 11. Studies, promotes, and aids in the adoption of the tenets of the Primary Care Medical Home (PCMH) accreditation program as they relate to care coordination and care management. 12. Participates in training programs to support the development and implementation of care coordination services for primary care patients. 13. Ability to work independently and make informed decisions pertaining to addressing patient needs. I 4. Perform other duties as assigned SAFETY: l. Knowledge of infection control competency: demonstrates understanding of and complies with universal precautions to reduce occupational exposure. 2. Understands fire safety procedures and MSDS related information. REQUIREMENTS: 1. Niagara County travel using personal vehicle 2. A valid driver's license and the ability to be insured by Niagara Falls Memorial Medical Center's Carrier 3. Excellent oral and written communication skills 4. Adept at learning and using computer systems. Efficient in using common Microsoft office suite (Excel, Word). 5. Experience in working with chronic disease including mentally ill, substance user, medically fragile individuals. 6. Ability to accurately document care plan notes electronically. 7. Must be flexible with hours based on needs of the population served by Niagara Falls Memorial Medical Center Health Home 8. Able to deal effectively with difficult situations 9. Ability to independently. Benefits Include: Generous Paid Time Off (PTO) Program Extended Illness Bank Competitive hourly rates Group Life Insurance Supplemental Short-Term Disability Medical Insurance, Dental Insurance Employee Assistance Program 403(b) Retirement \& Savings Plan Job-related Tuition Reimbursement Program Who We Are: Niagara Falls Memorial Medical Center is the only full-service hospital in Niagara County. The facility offers a 171-bed regional medical center with extensive inpatient and outpatient services, including a full-service Medical \& Psychiatric Emergency Room, The Heart Center of Niagara featuring an on-site Cath Lab, Niagara Wellness Connection Center, The Wound Center of Niagara, OB/GYN Center and UBMD Orthopedics \& Sports Medicine. We also offer a comprehensive range of surgical services. The first hospital in Niagara to be designated a stroke center by the New York State Department of Health, we operate several satellite facilities, including the Summit Healthplex, Tuscarora Health Center, primary care offices in Niagara Falls, Wheatfield, and the Town of Niagara. Schoellkopf Health Center, a 120-bed skilled nursing facility that specializes in short-term rehabilitation and elder care. Like the medical center itself, Schoellkopf features 100-percent private room accommodation. Niagara Falls Memorial's Child Advocacy Center of Niagara enjoys national accreditation. Our community health advocacy efforts coupled with extensive and productive community partnerships make us one of Western New York's most consistently innovative providers of community-based health outreach. As one of the Greater Niagara region's largest employers, we pride ourselves on playing an active role as an economic engine and a catalyst for community growth. Through growth and change, we remain faithful to our core mission: Improving the health of the Greater Niagara Region with a passion for excellence. Job Type: Full-time Pay: $27.00 - $33.00 per hour Expected hours: 37.5 per week Benefits: Dental insurance Health insurance Life insurance Paid time off Vision insurance Education: Bachelor's (Required) Experience: * Customer service: 5 years (Required) Work Location: In person