The Care Coordinator represents and supports the Adolescent & Young Adult Medicine clinic, Doernbecher Children’s Hospital (DCH), Ambulatory Care Services, and Oregon Health & Science University (OHSU) and its faculty and staff by providing excellent customer service and problem-solving skills. The role of the Care Coordinator is to provide support to the Adolescent & Young Adult Medicine Team (providers, residents, social workers, nurses, medical assistants, and schedulers) through the coordination of health maintenance care for our various patients including panel patients and those with complex and chronic health care needs and psychosocial issues. The Care Coordinator will coordinate care and ensure compliance with appointments through regular patient outreach via phone and will assist with panel management, data collection and will work with providers to ensure proper reporting and analysis. The Care Coordinator will also provide a full range of Medical Assistant duties and support as part of the medical care team as needed due to clinic demand. The Care Coordinator is a true team player who is flexible and helps when and where he/she is needed. This position functions within the Medical Assistant scope of boundaries as defined by OHSU. The Care Coordinator must demonstrate strong written and verbal communication with efficiency and diplomacy.

Service excellence, kindness, and compassion to all customers, including patients and other OHSU team members is an absolute requirement. Participates in ongoing professional development and competency assessment and participates in ongoing quality assurance and quality improvement initiatives. Performs requirements for staff members as outlined in OHSU Core Competencies, policies and procedures.

 

The Adolescent and Young Adult (AYA) Medicine Clinic provides comprehensive, age- appropriate care for individuals aged 10 to 25, focusing on the unique health challenges of this transitional stage. The clinic offers a wide range of services, including preventive care, mental health support, reproductive health, gender affirming care, eating disorders, and chronic disease management.

Patient Management

• Issues patient safety alerts to care team, along with lists of affected patients, for such events as drug recalls, warnings, or other potential safety issues.
• Scrubs (reviews and manages) patient charts the day prior to a visit to evaluate which health services are needed by each scheduled patient within the clinic. Updates Health Maintenance when necessary to ensure it properly reflects what health services patients are due for. 
• Performs daily outreach via cold calls, MyChart messages, and/or sending letters to schedule appointments or coordinate health services.
• Uses report writing programs, such as Reporting Workbench, through Epic and other software to identify patients for preventative health maintenance needs (i.e. immunization schedules, well child checks, etc.).
• Assists clinic with projects related to the Patient-Centered Primary Care Home (PCPCH) program aiding the coordination of patient- centered and effective care. 

Care Coordination

• Supports entire care team by helping patients and families with questions regarding referrals and tests or pending tests for clinician signature.
• Keeps a referral log of patient communication to ensure loop closure in care gaps from specialty referrals.
• Follows up on empaneled patients that have recently discharged from the Emergency Department (ED) or Inpatient (IP) services. 
• Outreaches to patient via phone calls and documents in a telephone encounter step encounter steps taken. Identify next steps needed (i.e. route to RN triage, schedule a follow up visit, etc.).
• Responsible for pre-visit planning including obtaining medical records, proactively obtaining medical records, proactively scheduling appointments, and updating health maintenance needs daily.
• Assumes a lead role in proactive outreach to patients related to individual health maintenance needs and overall panel management.
• Assist with securing and coordinating community resources, e.g. DME, home health, prescriptions including authorizations, etc.

Communication

• Coordinates process improvement cycles and implementation of new clinical workflows. Routinely participates, both inside and outside of clinic, in meetings related to quality improvement, care management, resident projects, and multidisciplinary patient conferences.
• Responds timely to voicemails, EMR messages and e-mail messages based on patient and care priorities.
• Provides information and education to patients and families and gathers information for specific visits. Prioritizes and responds to patient and family’s questions via MyChart, phone, e-mail, and fax in regard to schedule and care issues within scope. Escalate issues outside of scope. Escalates issues outside of scope, appropriately and timely.

Documentation/Data Management

• Document legibly, concisely and completely to ensure that others can accurately assess the status of patients’ progress by reviewing that documentation.
• Monitors department tracking tools and provides care team with real-time updates as appropriate. 

Other Duties as Assigned

Two years’ experience in a hospital or hospital-based clinic setting, AND

High School diploma or equivalent, AND 

Positions within person patient care: BLS certificate within 30 days of hire or prior to independent practice, whichever comes first, AND 

One of the following four: 

1. Completion of a nationally recognized accredited medical assistant training program, including a practicum (externship) of at least 160 hours, OR
2. Successful completion of a formal medical services training program of the United States Armed Forces, OR
3. Current Oregon Emergency Medical Technician (EMT) license (basic or advance) and national EMT registration with the National Registry of Emergency Medical Technicians (NREMT), OR
4. Current Oregon Practical Nurse License 

For those completing medical assistant training or formal military medical services training as referenced above in #1 and #2, the following is also required (Those qualifying under the EMT or LPN qualification are exempt from this requirement.) 

MA certification received from a nationally recognized and accredited certifying body, upon hire or by the completion of the probationary period or internal job change evaluation period, as appropriate. Currently, these include: 

• The American Association of Medical Assistants (AAMA), awarding the Certified Medical Assistant (CMA.)
• The American Medical Technologists (AMT), awarding the Registered Medical Assistant (R.M.A.)
• The National Center for Competency Testing, awarding the National Certified MA (NCMA.)
• The National Health Career Association, awarding the Certified Clinical Medical Assistant (CCMA.) 

Any applicable certifications or licensures must be maintained for the duration of employment. 

 

In addition to receiving the appropriate certification noted above, Medical Assistants will be required to successfully demonstrate competencies prior to completion of probation or the internal job change evaluation period, as appropriate. 

 

Ability to work independently and as a member of the team, including leadership.

Knowledge of patient flow and back-office functions. Ability to effectively and efficiently perform chart scrubbing and panel outreach activities. Demonstrated strong analytic skills, including displaying and interpreting data. Proficiency with EPIC, Microsoft Office including Excel, Word and Power Point. Ability to manage time sensitive competing demands and meet deadlines. Working knowledge of medical terminology.  Strong relationship building skills, excellent communication skills, exceptional customer service skills, highly sensitive to patient needs. 

• AA or BS in Business, or Health Care related field.
• Experience working in a Pediatric or Primary Care setting.
• Prior experience working in a Patient-Centered Medical Home.
• Experience performing chart scrubbing and proactive panel management activities. 

Job Related Knowledge, Skills and Abilities (Competencies):

• Use of Epic, Business Objects, Webi.
• Understanding of age specific preventative health maintenance indicators and disease specific standards of care for those prevalent in underserved pediatric patient populations. 

Adolescent & Young Adult Medicine is a subsidiary of General Pediatrics, originally operated as a single entity. As part of this transition, the AYA medical assistants/care coordinators will support the general pediatrics clinic based on operational need, determined by leadership.

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To request reasonable accommodation, contact askhr@ohsu.edu