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Job Details The Care Manager Coordinator assists clinical staff in the collaborative process of assessment, planning, implementation and evaluation, to engage and educate patients in obtaining or maintaining optimal health status. Summary of Duties: Filters/scrubs population to identify high risk patients, and forward to appropriate clinical team member. Completes initial phone contact and intake form. Maintains patient population for ongoing outreach and follow up. Identifies and escalates quality of care issues under the guidance of a Registered Nurse. Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimal health status. Provides coaching, information and support to empower the member to make ongoing independent healthy lifestyle choices. Communicates with other team members regarding potential impact of Social Determinants of Health that may impact beneficiaries health and treatment plan. Monitoring, evaluation and documentation of care. Completes community resource referrals based on SDOH screening and recommendations from Patient’s Case Team. Reviews inpatient list, outreaches to hospitals and practices for patient information. Engage patients with chronic conditions to reinforce following the care plan, adjusting tasks to fit with the patient’s culture, language, and religion, improve access to care, identify health care needs, and reduce unnecessary hospitalizations and emergency department visits. Report any changes in patients status or a need for clinical education to the RN Care Coordinator and/or Nursing Supervisor Work to reduce cultural and socio-economic barriers between patients and health care team Assist beneficiaries to identify socio-economic issues that affect their overall health and develop health/social management plans and goals Telephonic and onsite work days. CH Hospital onsite rounds as needed Identifies Gaps in Care and monitor for closure of gap. Other duties and tasks as required Qualifications, Skills and Knowledge Required: High School graduate or above. 2-5 years of experience in a Health Care environment or equivalent background with a strong understanding of the medical field. Computer literacy, including Microsoft Office, data entry, retrieval and report generation. Ability to communicate medical information to health care professionals and care coordination over the telephone Knowledge of formal and informal community agencies and resources, or knowledge of how to research. Working knowledge of multi- system outreach programs relate to health care delivery, clinical education, and health-related services Experience with Electronic Health Records applications. A team player that can follow protocols to achieve a common goal. Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community Confidence to outreach to other health care organizations and personnel. Must have private, secured workplace Sensitivity to cultural diversity Other duties/tasks as needed Salary Range USD $25.00 - USD $30.00 /Hr.