Clinical Care Coordinator/ Must be IMG! - The Bronx, NY

Job Description Job Description Position Title: Clinical Care Coordinator – House Calls – ACO REACH/VBP Team Position Summary: The Clinical Care Coordinator works in collaboration with the primary care provider and all members of the care team. Develops care initiatives to assess and coordinate chronic disease care management for their patient population in a manner that is medically appropriate and cost effective. Responsible and accountable for direct and indirect patient care for designated patient populations. Assesses healthcare needs and identifies community resources. Serves as patient advocate and assists in identification and improvement of service delivery. Essential Functions: o Collaborate in overseeing patient’s clinical and social care. o Conduct face-to-face assessments for all patients to assess their medical and social needs twice a week o Schedule appointments and transportation o Take hotline calls and serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s) and community resources o Facilitate patient access to appropriate medical and specialty providers o Educate and refer patient to community resources o Develop a comprehensive, collaborative care plan, based on provider treatment plan, evidence-based chronic care guidelines, and patient/family goals for patients in the chronic disease registries, recent discharges, and those in care transition to promote adherence to provider recommendations and instructions. o Assist with and facilitate the transition of care from inpatient settings such as hospital, rehabilitation facilities and skilled nursing facilities to home. o High risk and chronic disease management including: o Provide care via face-to-face, telephonic and/or electronic communication. o Provide individual patient/family education and self-management support that is appropriate based on language, cognitive abilities, literacy level, learning style, cultural norms, patient preference, readiness for change and resources available. o Address medication adherence. o Provide education to patients regarding health conditions. o Collaborate in goal planning and care management. o Communicate changes in patient’s status appropriately with the care team. o Perform all follow-up requests, with patient when appropriate. o Identify barriers when treatment goals are not met, treatment plan is not being followed or important appointments are missed. o Collaborate in developing patient treatment goals. o Identify patients who are overdue for visits, labs and referrals, contact patients and arrange for follow-up services. o Assist the patient in improved healthcare access and promote patient knowledge of health and behavior change. o Facilitate the initiation of diagnostic services, treatment planning and therapeutic treatment. o Utilize appropriate protocols and standing orders in delivering patient care. o Report quality measures. o Serve as a clinical and social needs resource and community referral resource. o Assist providers during home visits. o Participate in regular team meetings, huddles, staff meetings and quality improvement projects to improve patient care. o Consult staff to eliminate barriers to the efficient delivery of care. Identify service delivery problems and potential for effective patient management intervention. · Perform all other duties as assigned. Competencies: · Ability to work independently and exercise clinical judgment in interactions with providers, patients and their families. · Strong organizational and time management skills, as evidenced by a capacity to prioritize multiple tasks and role components. · Strong analytical and data management skills. · Aware of scope of practice boundaries, comfortable seeking direction and assistance from appropriate resources. · Communication – Ability to communicate effectively verbally and in writing. · Computer Skills – Proficient ability to use a computer and electronic medical record, preferably e-Clinical Works (eCW). · Confidentiality – Maintain patient, team member and employer confidentiality. Comply with all HIPAA regulations. · Customer Service Oriented – Friendly, cheerful and helpful to patients and others. Ability to meet patients and others needs while following office policies and procedures. · Flexibility – Ability to adapt easily to changing conditions and work responsibilities. · Positivity – Display a positive attitude and is a positive agent for change. · Teamwork – Work as part of a team and collaborate with co-workers. Education and Experience: · International Medical Graduate, Medical Assistant, and/or Home Health Attendant o Medical Graduation (International or National) Passed portions of the United States Medical Licensing Examination (USMLE) o Educational Commission for Foreign Medical Graduate (ECFMG) o Computer savvy – Word, Excel, PowerPoint, Adobe o Bilingual Spanish strongly preferred Company Description At Essen Health Care, we care for that! As the largest privately held multispecialty medical group in the Bronx, we provide high-quality, compassionate, and accessible medical care to some of the most vulnerable and under-served residents of New York State. Guided by a Population Health model of care, Essen has five integrated clinical divisions offering urgent care, primary care, and specialty services, as well as nursing home staffing and care management. Founded in 1999, our over 20-year commitment has fueled an unwavering dedication toward innovating a better healthcare delivery system. Essen has expanded from a single primary care office to an umbrella organization offering specialties from women’s health to endocrinology, from psychiatry to a vast array of other specialties. All clinical services are offered via telehealth or in-person at over 35 medical offices and at home through the Essen House Calls program. Essen Health Care is the place Where Care Comes Together! We are looking for the most talented and effective individuals to join our rapidly growing company. With over 1,100 employees and 400 Practitioners, we care for over 250,000 patients annually in New York City and beyond. From medical providers to administration & operational staff, there is a career here for you. Join our team today! Company Description At Essen Health Care, we care for that! \r\n\r\nAs the largest privately held multispecialty medical group in the Bronx, we provide high-quality, compassionate, and accessible medical care to some of the most vulnerable and under-served residents of New York State. Guided by a Population Health model of care, Essen has five integrated clinical divisions offering urgent care, primary care, and specialty services, as well as nursing home staffing and care management. Founded in 1999, our over 20-year commitment has fueled an unwavering dedication toward innovating a better healthcare delivery system. Essen has expanded from a single primary care office to an umbrella organization offering specialties from women’s health to endocrinology, from psychiatry to a vast array of other specialties. All clinical services are offered via telehealth or in-person at over 35 medical offices and at home through the Essen House Calls program. \r\n\r\nEssen Health Care is the place Where Care Comes Together! We are looking for the most talented and effective individuals to join our rapidly growing company. With over 1,100 employees and 400 Practitioners, we care for over 250,000 patients annually in New York City and beyond. From medical providers to administration & operational staff, there is a career here for you. Join our team today!

Location: New York City, NY, US

Posted Date: 5/3/2025