Clinical Care Coordinator (ACO- House Calls)

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    "datePosted": "2025-05-12T04:00:00.000Z",
    "description": "<h2>Overview</h2>\n<p><em>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.</em></p>\n<p> </p>\n<p><em>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.</em></p>\n<p><em>We also provide nursing home support, care management services, and in-home medical services through our House Calls Division, Intention Health Care and facilitate smooth transitions between care settings including telehealth, in-person medical visits, and home care through Intention Health Care. </em><em>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.</em></p>\n<p> </p>\n<p><em>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.</em></p>\n<h2>Job Summary</h2>\n<p><strong>Position Title:</strong> Clinical Care Coordinator (ACO- House Calls)</p>\n<p> </p>\n<p><strong>Job Summary:</strong> The Clinical Care Coordinator is a key member of the outpatient care team, responsible for delivering in-home clinical services to patients. Closer in function to a clinician than an MA, you will be responsible for conducting your own house calls, and managing care holistically for a defined panel of complex polychronic patients in collaboration with a doctor or APC. This role focuses on supporting patient care plans, coordinating with providers, and ensuring a high standard of care during house call visits. The coordinator serves as a liaison between patients, families, and healthcare professionals, helping to ensure seamless communication, proper follow-up, patient education, and creative problem solving to remove barriers to care. A driver is provided to assist with travel, allowing the coordinator to focus on clinical responsibilities and patient engagement.</p>\n<h2>Responsibilities</h2>\n<p><strong>Conduct In-Home Patient Visits</strong></p>\n<p>· Provide clinical care to patients in their homes, including assessments, health screenings, and follow-ups as directed by the provider or care plan.</p>\n<p>· Highlight care gaps and opportunities for clinical and nonclinical interventions that will help patients achieve better health outcomes.</p>\n<p>· Ensure each visit adheres to quality standards and organizational protocols.</p>\n<p><strong>Coordinate Patient Care Plans</strong></p>\n<p>· Collaborate with physicians, nurse practitioners, and other healthcare team members to support individualized care plans.</p>\n<p>· Monitor progress and make recommendations for care adjustments as needed.</p>\n<p><strong>Patient Education & Suppo</strong>rt</p>\n<p>· Educate patients and caregivers on disease management, medication adherence, and self-care techniques.</p>\n<p>· Address patient questions and concerns in a compassionate and professional manner.</p>\n<p>· Conduct medication reconciliation for our high-needs population who often struggle with polypharmacy issues, especially as they move among care settings.</p>\n<p><strong>Documentation & Reporting</strong></p>\n<p>· Accurately document all visits, assessments, and communications in the electronic medical record (EMR) system in a timely manner.</p>\n<p>· Ensure compliance with all regulatory and organizational documentation standards.</p>\n<p><strong>Coordinate Services & Follow-Up Appointments</strong></p>\n<p>· Suggest and implement clinical initiatives designed to help avoid unnecessary hospitalizations.</p>\n<p>· Assist with referrals, appointment scheduling, and coordination of ancillary services such as labs, imaging, or home health, if needed.</p>\n<p>· Follow up on pending results or care actions and relay relevant information to the healthcare team.</p>\n<p><strong>Maintain Communication with the Care Team</strong></p>\n<p>· Act as a liaison between patients, families, and the broader care team to ensure continuity of care and timely updates.</p>\n<p>· Escalate clinical concerns to the appropriate provider as necessary.</p>\n<p><strong>Ensure Compliance & Patient Safety</strong></p>\n<p>· Adhere to all infection control policies, privacy regulations (HIPAA), and safety guidelines during home visits.</p>\n<p>· Maintain necessary clinical supplies and ensure equipment is in working order.</p>\n<p><strong>Transportation & Logistics Coordination</strong></p>\n<p>· Work closely with assigned drivers to ensure timely and efficient routing for home visits.</p>\n<p>Manage daily schedules to maximize patient access and minimize travel disruptions.</p>\n<h2>Qualifications</h2>\n<p>· Proficiency in both English and Spanish (additional languages a plus)</p>\n<p>· Medical Degree (International or National)</p>\n<p>· Successfully completed Essen Medical Clinical training</p>\n<p>· The ability to work independently and exercise clinical judgment in interactions with providers, patients, and their families/caregivers</p>\n<p>· Good bedside / telephone-side manner</p>\n<p>· Good communication and computer skills, and cooperative attitude</p>\n<p> </p>\n<p><em><strong>· Salary Range: $20-22 / hr, plus a quarterly bonus based on ability to help patients avoid unplanned hospitalizations.</strong></em></p>\n<h2>Equal Opportunity Employer</h2>\n<p><strong><em>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.</em></strong></p>",
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