Coordinator

Assist all patients through the health care system by acting as a patient advocate and navigator. * Participates in Patient Centered Medical Home team meetings and quality improvement initiatives. * Facilitates health and disease patient education, including leading group office visits. * Supports patients’ self-management of disease and behavior modification interventions.

Coordinates continuity of patients and families following hospital admission, discharge, and ED visits. * Conducts comprehensive, preventive screening for patients and/or assists all support staff in daily patients interactions as needed. * Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.

Facilitates patient medication management based upon standing orders and protocols. * Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Patient Centered medical Home and Medical Neighborhood initiatives. * Evaluates clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.

A team player that can a follow a system and protocol to achieve a common goal. * Highly organized and well-developed oral and written communication skills. * Demonstrates sound judgement, decision-making and problem solving skills. * Able to obtain confidentiality with all aspects of information in accordance with practice, State and Federal regulations.

Confidence to communicate and outreach to other community health care organizations and personnel. * Self-disciplined, energetic, passionate, innovative. * Performs all other duties as required. * Assist all patients through the health care system by acting as a patient advocate and navigator. Billingual preferred Formal Education and Job-Related Experience