The Care Coordination Specialist (CCS) for the Peninsula Regional Clinically Integrated Network (PRCIN) functions as a key member of the primary care practice team. Under the supervision of the PRCIN Care Coordination Supervisor, the CCS is responsible for providing care coordination services to moderate and high risk patients ensuring safe and effective transitions across the health care continuum to include the ambulatory care setting, hospital, home environment, and skilled nursing facilities. The CCS serves as a care resource and coach with a focus on the health and wellness, prevention, and social determinants of health, and in collaboration with the practice-based health care team develops and implements a patient-centered plan of care that promotes self-care. The primary Duties of the Position include practice-based care coordination for patients at risk for health deterioration, poor outcomes, and/or high resource utilization, and identifying social, environmental, and financial needs and coordinating referral to community resources as appropriate. The Care Coordination Specialist will motivate patients to complete specific health care tasks related to an improvement in health, as well as provide disease specific education to assist patient in self-management of condition. They will also be responsible for the collection and analysis of data relating to team and population health metrics.
- Bachelor's of Science Degree in Community Health Education or Health Sciences, and/or minimum of 4 years of experience working in a clinical and/or administrative role in an acute care or community outpatient setting.
- Experience with EMRs - Epic preferred.
- Advanced knowledge and proficiency in Word, Excel, and, Power Point; experience in data compilation, analysis, tracking, and entry.
- Community (Population Health), Emergency Department, outpatient medical office, and/or inpatient hospital experience preferred.
- Must have valid driver’s license, and ability to travel to and from care centers to meet with patients and providers.
- Preferred experience educating and engaging patients.
- Knowledge of local community resources.
- Demonstrates ability to function autonomously and be directly accountable for individual work and outcomes.
- Must be able to organize effectively, work under constraints of time, pressure, accuracy, and interruptions.
- Must possess good interpretive and communication skills, both oral and written.
- Demonstrates ability to influence and negotiate individual and group decision-making.
- Applies critical thinking in decision-making when evaluating alternatives and determining best plan of action for patients and families.
- Committed to team goal and organizational goals, and prioritizes daily activities to meet those metrics.
- Team focused - understands the need to work as a group to achieve goals, support team members, and listen to other points of view.
- Strong service excellence skills, including effective and timely communication, compassion, persuasion, and helpfulness when interacting with patients, families, general public, and other health professionals.
- Maintains and exhibits a positive mental attitude.
- Readily assumes additional responsibilities to meet with the needs of the team and practice.
100 E Carroll St.,Salisbury, MD
Patient Care Management Service
Varied day and weekends