The Outreach Care Coordinator supports GLBHC's participation in an Accountable Care Organization (ACO). This position will complete health risk assessments on all assigned Medicare patients, support patients with how to effectively communicate with their primary care provider and care team and assist with community resources for SDOH (Social Determinants of Health). This position participates in a team-based approach to care in the Patient-Centered Medical Home (PCMH).

ESSENTIAL JOB DUTIES

1. Responsible for outreach to all identified Medicare patients and completion of health risk assessments as defined by the agreement. (30%)
2. Assist with scheduling appointments to address care gaps and inpatient discharge & emergency department follow-up visits for patients. May assist with outreach to patients related to missed and/or cancelled appointments to close gaps in care. (20%)
3. Assisting patients on how to effectively communicate with their PCP (Primary Care Provider) and care team. (20%)
4. Work with GLBHC (Great Lakes Bay Health Centers) Community Health Workers for patients who have an identified social determinate of health risk in areas such as: housing, food assistance, clothing, utilities, transportation etc. (20%)
5. Utilize tracking tools to help identify patients considered "high risk" for the purpose of transition to a Care Manager for follow up care. (10%)

Note: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

MARGINAL JOB DUTIES

1. Assists with patient tracking as needed.
2. Follows up with patients referred to our health center to ensure they receive services and discusses their utilization of the programs available to them.
3. Contacts patients that do not show up for their appointments, or that require recall, encouraging their continuity and completion of care.

JOB SPECIFICATIONS

1. Education: High school diploma or Certification as a Medical Assistant required.
2. Experience: Minimum of one year experience in a medical setting preferred.
3. Skills: Excellent telephone etiquette. Computer use including word processing, excel, and Electronic Health Records. Able to operate office equipment including computer, fax machine, copy machine, etc. Able to follow through with assignment responsibly, accurately and efficiently.
4. Interpersonal Skills: Ability to communicate effectively with, and relate to a diverse population in a professional and courteous manner. Ability to follow oral and/or written instructions. Knowledge of insurance plans helpful. Able to work independently and as a team member.
5. Physical Effort: Must be able to sit, stand, and or walk for an entire workday. Must be able to lift, carry, push, pull, and or twist while holding up to 25 lbs. occasionally.
6. Hours: Full time, flexible and varied. Evening hours may be required.
7. Travel: Interoffice travel to each center is required.

GLBHC is an equal opportunity employer and prohibits discrimination and or harassment based on race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, and or local laws.