Job Summary:
At MyCare Medical, we strive to make sure our patients receive the highest quality, most cost-effective care. We have a dedicated High-Intensity Care (HIC) team supporting our patients, giving them the time that they need to care for each patient and ensure a comfortable and patient-centric experience. The High Intensity Care Coordinator, under medical supervision, assists the High Intensity Care (HIC) Provider in the delivery of health care services.Job Responsibilities:Access to care: The HIC Primary Care Provider (PCP) has ultimately responsibility for the clinical management of each HIC patient.

HIC Coordinator ensures patients are seen at least once per month and as necessary by HIC PCP and team.
Outreaches HIC patients to engage them with HIC program based on acuity.
Schedules PCP HIC visits and ensure adherence with scheduled appointments.
Answers calls and messages from HIC patients during business hours. Patients have a dedicated phone number to call 24/7 that connects to one of the HIC Provider to which they are assigned.
Adheres to the process for adding a HIC visit during the day for urgent symptoms, destabilization, and transitions of care.
Coordinates virtual visit capabilities when available and clinically appropriate, and when patients can use technology.

DURING THE HIC VISIT:

Obtains patient vitals, and assist Provider with minor procedures, injections (therapeutic/immunization), phlebotomy, collects appropriate consents prior and during visit.
Educates patients on “Call us first”.
Captures quality care gaps, screenings, and recommended care for primary, secondary, and tertiary preventions should be addressed and closed on all patients.
Assist in obtaining Advanced Care Planning and DNR documents.
Other tasks as assigned.

BETWEEN HIC VISITS:

Coordination of care between HIC visits.
Coordination of labs, DME, home health, home infusion, dialysis program, HEDIS measures, and referrals and supports hospice referrals.
Coordinate integrated collaborative, embedded behavioral health and SDOH (TBD) (use current Health Plans BH/SDOH when available).
Retrieve every specialty consult note. Referral must be approved by the HIC PCP in coordination with assigned PCP (if/as needed).
Assist HIC Provider in communicating with hospitalist/SNF team when patient is referred to ED, admitted to the hospital/SNF, and discharge from ED/Hospital, SNF.
Assist/coordinate HIC APP (TBD) to visits HIC patients at home as indicated by HIC provider.
Participate with HIC team in regularly schedules huddles/case conferences to review all/some patients at least once a week.
Verify patient eligibility and appointment confirmation before every HIC appointment.
Do wellness check in calls with patients every week.
Assist to dispatch MyCare at Home as needed.
Assist in obtaining hospital records and scheduling transition of care management visits.

Job Qualifications:

Medical Assistant Certificate issued by an accredited institution OR

One (1) year of experience working in a health care setting that includes direct patient contact OR
A combination of training, education, and experience that is equivalent to one of the employment standards listed above and provides the required knowledge and abilities.
Bilingual in English/Spanish preferred but not required
Electronic Medical Record (EMR) experience, preferably eClinical Works (eCW)
Basic medical terminology; Basic arithmetic.
Safe vein puncture techniques, and knowledge of safe work practices in a clinic setting.
Able to speak clearly and communicate effectively over the phone and in-person.

BENEFITS