Patient Centered Medical Home (PCMH) Coordinator

What you'll be doing: Provide telephonic outreach and in-person consultation to members identified as high risk, having a chronic condition(s) and in need of preventive services. In collaboration with the physician, assess clinical information to develop and a member specific care plan. Assist with coordination of care/services as well as care transitions working with both internal and external entities. Establish measurable goals that promote evaluation of the cost and quality outcomes of the care provided. Collaborate with healthcare team to optimize patient adherence to medical plan of care, including: medication adherence, evidence based care, and specific screenings for recommended preventive care. Utilize BCBST population health management tool, care team connect (CTC), to improve quality outcomes, reduce unnecessary tests, document care plan, care notes and a psychosocial risk assessment on each member. Develop individualized goals with members to improve adherence and outcomes. Interact with other departments to ensure the smooth transfer of member information across the continuum of care.

What your background should be: Minimum of 5 years healthcare w/3 years clinical experience required. 2 years experience in utilization management, case management or care/disease management. Must be PC literate with extensive knowledge of Windows and Microsoft Office. Exceptional skills of independence, organization, communication, problem-solving, professional interaction, and human relation skills, as well as analytical skills and problem solving ability.

Who is the client company: The company provides health insurance plans.; If you are interested in this position, send your resume to apply@kochdavis.com