Care Coordination Specialist TMIN Southern Region (tuftsmedicine)

Job Description

We are hiring for individual role in the following covered regions:

• South - Plymouth & Barnstable counties

This position is primarily remote, requiring 25% - 50% of travel possibly. CCSs are asked to make in-person practice introductions, attend practice meetings when necessary to discuss quality and performance alongside their practice POM, and if one of the assigned practices does not give remote EMR access to patient records; the CCS would have to travel to the practice to obtain in person.

Our Integrated Network brings together a diversity of experienced private practice and employed physicians as well as community and academic providers. While we are one unified network, we focus on different geographic regions, with local care teams convening to ensure healthy, happy neighborhoods throughout the greater Boston region.

Job Overview

This position works in collaboration with the multidisciplinary health care team, providers, and patients to engage the patient in their plan of care and ensure coordination and completion of open quality measures care gaps. 

Job Description

Minimum Qualifications:

1.  High School diploma or equivalent.

Preferred Qualifications:JOB IS FROM: nursingjobs.siteVIEW

1. Some College Coursework.

2. Medical Assistant Certification.

3. Two (2) years of health care customer service or call center experience.

4. Bilingual.

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list.  Other duties and responsibilities may be assigned.

1. Facilitates multiple components of patient care including but not limited to scheduling, gaps in care closure, and ensuring all collected data is entered into the designated care management module timely and accurately.

2. Generates and receives calls from patients and providers to coordinate services to satisfy high risk member needs.

3. Provides support to the RN Care Manager in administrative tasks related to referrals of high-risk members to other Health Management Programs, services, and community resources.

4. Reports any possible issue related to the member’s health care to the appropriate stakeholder, such as the Nurse or other member of the multidisciplinary health care team in a timely manner.

5. Provides monitoring and outreach as indicated for members who are not enrolled in a total care program, but may need gap in care closure, annual HRA, or monitoring for a change in condition/status. 6. Documents all calls, outreach attempts, interventions/activities, and any additional information in the appropriate electronic tool and/or platform.

6. Facilitates chart/record submission, portal data entry, and supplemental data submission to various payers as required.

7. Assists with Care Navigation.

8. Completes proactive outreach and engagement for patients with open care gaps to assist with care gap closure.

9. Generates reports as required.

Physical Requirements:

1. Ability to sit for extended periods of time.

2. Prolonged standing and walking.

3. Occasional twisting, bending, reaching, pushing/pulling, sitting, kneeling, and squatting.

Skills & Abilities:

1. Basic knowledge of medical/clinical terminology.

2. Ability to work with Microsoft Office in an efficient and productive manner (Word, Excel, Power Point, Microsoft Teams, and Outlook).

3. Able to be respectful of organizational and individual cultural diversity and compassion towards the member population.

4. Accurate time management.

5. Effective verbal and written communication skills.

6. Ability to interact with people at all levels of the health care system.

7. Ability to solve problems and prioritize and complete multiple tasks.

8. Uses logic and reasoning to identify barriers and effective solutions and different approaches for problem solving.

9. Ability to adapt to different scenarios and constant changes. 

10. Knowledge of population health.

Job Profile Summary

​This role focuses on performing activities associated with evaluating, developing, recommending, implementing, and carrying out the policies and procedures related to the delivery of high quality patient care.  In addition, this role focuses on performing the following Customer Service duties: Guides the patient through the healthcare system and works to overcome obstacles that are in the way of the patient receiving the care and treatment they require.  An organizational related support or service (administrative or clerical) role or a role that focuses on support of daily business activities (e.g., technical, clinical, non-clinical) operating in a “hands on” environment.  The majority of time is spent in the delivery of support services or activities, typically under supervision. An entry level role that typically requires little to no prior knowledge or experience, work is routine or follows standard procedures, work is closely supervised, and communicates information that requires little explanation or interpretation.