ACO Annual Wellness Coordinator

Job Summary: Centered in an Accountable Care Organization (ACO) department, this individual works in partnership with patients, families, nurses, physicians, and other qualified healthcare providers and clinical disciplines.
Coordinates care for Medicare patients with chronic disease and manages effective care transitions for them within the continuum.
Partners with the provider care team for successful annual preventative care visits to reduce the severity of chronic disease and avoidable acute illness.
Provides effective clinical health coaching to assist patients with self-management of their chronic disease and life-style changes to mitigate health risk.
Promotes effective partnerships and utilization of community resources.
Facilitates a “shared goal model” within Artesia Healthcare Professionals and across settings to achieve coordinated high-quality care that is patient and family-centered.
ESSENTIAL FUNCTIONS: Supports the functions of the ACO Department.
In collaboration with ACO Director and practice leaders, establishes and maintains an effective internal tracking system for patients such as annual wellness visit scheduling, transition of care follow-up calls and timely provider visits.
Reviews clinic schedules and generates reports to identify patients appropriate and/or due for a Medicare annual wellness visit.
Builds positive, open communication between patients, caregivers, providers and staff, and works as a team member to enhance the patient experience.
Ensures that all required elements are documented for the AWV scheduling and communication with the patient care team to help satisfy quality gaps.
Acts as a patient advocate.
Reviews and adheres to all Medicare guidelines regarding the performance of Annual Wellness Visits.
Serves as a contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources.
Ensures effective tracking of test results, medication management, and adherence to follow-up appointments.
Facilitates and attends meetings between patient, caregivers, care team, payers, and community resources as needed.
Attends and actively participates in all Care Coordination related training and meeting activities (Health Coach certification, quarterly Regional Workshops, monthly cohort calls with other Care Coordinators and Caravan Health CC Program Coach) as assigned.
ADDITIONAL RESPONSIBILITIES: As assigned POSITION COMPETENCIES: Core Values consistent with a patient/family-centered approach to care.
Demonstrates professional and effective written and verbal communication skills.
Demonstrates understanding in use of IT resources and patient databases.
Demonstrates a positive, respectful attitude and professional customer service.
Acknowledges patients’ rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations.
Proactively acts as a patient advocate, responding with empathy and respect to resolve patient/family concerns.
Recognizes and responds to opportunities for improvement.
Demonstrates continual learning skills, effects change in approach to care based on established, evidence-based practice.
Demonstrates professional practice behavior.
Assists with mentoring/coaching of other care coordination team members.
Cultivates effective partnerships, effectively collaborates with all practice providers (Physician, Nurse Practitioner, Physician Assistant and other licensed allied health team-members).
Risk Management/Quality Management/Safety: Cooperates fully in all Risk Management, Quality Management, and Safety Activities and Investigations.
MINIMUM POSITION QUALIFICATIONS: Current licensure as a Licensed Practical Nurse (LPN), Certified Medical Assistant (CMA) preferred, or other healthcare related certification.
Two years’ experience in provider practice or clinic health setting preferred.
BLS certification required Strong critical thinking skills.
Attention to detail and accurate documentation.
Ability to work in a high-volume caseload environment and deal effectively with rapidly changing priorities.
Effective organizational, leadership, communication, education, collaboration, and counseling skills.
Previous care coordination or annual wellness experience preferred.
Experience with post-acute care facilities and the ability to mobilize community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.
Ability to speak a relevant second language - bilingual (English/Spanish) preferred.
Previous experience with health IT systems and data reports preferred.
Demonstrated ability to work constructively with all disciplines related to caring for patients within the community.