The following is a list of duties and responsibilities for the care coordinator:
Patient Care Coordination
• Participate in morning huddles to anticipate the patient’s clinical, social and behavioral health
• Work with the care team to identify gaps in care and work to resolve them using process
• Provide brief interventions at point of care to assist patients with management of their chronic
illness, address any social needs and link patients to behavioral health.
• Send letters and perform follow-up phone calls to patients for planned visits.
• Advocate for patient services with community, social service, and medical providers.
• Participate and coordinate care transitions for patients who have been seen in an emergency room
and/or have been discharged from a hospital/long-term care facility.
• Connect patients to Sea Mar and non-Sea Mar resources as appropriate and track all resources
available to patients. These services may include but are not limited to insurance enrollment,
preventive health services, behavioral health, dental, and care management.
• Assist patients with ongoing self-management goal setting based on mutual goal setting and with
emphasis on client decision-making utilizing motivational interviewing skills.
• Follow up with patient to evaluate their condition and address barriers to care plan.
• Track patient’s adherence with plan of care in electronic or paper charts and communicate
outcomes and recommendations to the primary care provider.
• Participate in group visits and planned visit events providing care coordination support.
• Disseminate information regarding care for chronic illnesses and/or mental health and behavioral
issues to the clinical care team.
• Maintain indigent patient medication assistance program and dispense 340b medications and
supplies depending on the clinic site.
• Exhibit excellent customer service skills by using active listening skills, greeting patients in a
welcoming manner, making them their only priority when providing services and assist in meeting
• Other duties as assigned by the Health Center Administrator and/or the Health Education & Care
Coordination Program Manager.
• Function as a point person within the clinic care team regarding chronic disease management and
improvement activities to improve clinical quality measures.
• Identify patients for gaps in care that need to be addressed in the huddle.
• Organize monthly Health Home meetings by working with the Clinic Operations Team/Clinic
Manager, create the agenda and help facilitate the meeting.
• Track and promote quality improvement initiatives related to chronic care (chronic disease) and
behavioral health integration.
• Submit PDSA activities to the Clinic Manager on a monthly basis as part of the QI process.
• Work closely with care team members and hold team meetings monthly or as needed when
implementing new systems.
• Collaborate with clinical care team to improve Patient-Centered Medical Home processes and
provide documentation demonstrating performance.
• Generate reports for care teams to identify areas of improvement and monitor sustainability of
• Review the medical record for quality and utilization indicators according to the Quality
• Train new clinic staff on the Chronic Care Model and Patient-Centered Medical Home.
• Participate in inviting patients to set up their Follow My Health account and provide brief
information about the benefits of it.
• Other duties as assigned