Clinical Care Coordinator (ACO- House Calls)

Essen Health Care is the largest privately held, multispecialty medical group in New York, providing high-quality, compassionate care to some of the state’s most vulnerable and underserved residents.

Founded in 1999, we’ve grown from a single primary care office into a network of 50+ locations offering urgent care, primary care and specialty services, from women’s health to endocrinology and psychiatry. We also provide nursing home support, care management, and in-home care through our Essen House Calls program. Guided by a Population Health model, our team of 500+ providers deliver care in-person, at home, or via telehealth, ensuring patients get the support they need when and where they need it.

We’re looking for talented, motivated individuals to join our growing team. Whether you’re a medical provider, administrator, or operations professional, there’s a career here for you. Join us in making a real difference in the health of our community.

The Clinical Care Coordinator (CCC) works in collaboration with the primary care provider and all other members of the care team to support chronic disease care management for high-risk, high-need patients in a manner that is medically appropriate and cost effective. As a patient advocate, the CCC is responsible for direct and indirect patient care, helps identify clinical and health-related social needs and connects patients with relevant community resources.

Conduct telephonic and in-person communication with patients to support the provider in addressing patients’ medical and social needs.

o Occasionally visit patients in their homes to support proactive and efficient care delivery, and to evaluate patients signs, symptoms, and social needs.

o Serve as the contact, advocate, and informational resource for patients, care team, family/caregiver(s) and community resources.

o Facilitate patient access to appropriate medical and specialty providers.

o Educate and refer patients to community resources.

o Develop a comprehensive, collaborative care plan, based on provider treatment plan, evidence-based chronic care guidelines, and patient/family goals for patients to promote adherence to provider recommendations and instructions.

o Assist with and facilitate the transition of care from inpatient settings such as hospital, rehabilitation facilities and skilled nursing facilities to home.

o Address medication adherence.

o Complete daily tasks such as taking clinical notes, reviewing medical records, following up on care gaps, coordinating chronic disease care, and other duties as assigned.

o Provide education to patients, families/caregivers regarding resources for health care management, and condition exacerbations.

o Communicate changes in patient’s status timely with the care team.

o Work with the Administrative staff to provide feedback that can assist in identifying and improving day-to-day operational processes.

Standard Hours Per Week: 40. Mostly in-person.

Would you describe yourself as someone who has:

· International Medical Degree

· Fluent in English and Spanish is a plus

· Some amount of experience in health care, preferably in care management or another patient-facing role

· A strong customer-service orientation, and extremely good verbal communication skills. Are you someone who’s going to run through walls to make sure our vulnerable patients get the care they need, despite the many barriers to care they face?

· The ability to work independently and exercise clinical judgment in interactions with providers, patients, and their families/caregivers

· Ability to function in a fast-paced environment, to be held accountable for high performance standards, and to hold others accountable for high performance

· Strong Familiarity with Electronic Health Records (EHR), able to review a medical chart for evidence of a disease

Essen Health care is proud to be an equal opportunity employer, and we seek candidates who desire to work in and serve an ethnically diverse population.