The goal of the Practice Panel Coordinator is to help practices meet the goals of the Maryland Primary Care Program. The PPC will empanel and risk-stratify individuals within a doctor's primary care practice so that all attributed patients get the right care at the right time and place, in order to improve health outcomes and control costs. The PPC is an essential part of the advanced primary care team and facilitates this work. The PPC uses data to determine which patients are experiencing gaps in care and finds effective, patient-centered ways to close those gaps. Many patients face non-medical challenges that get in the way of their health objectives. The PPC's focus is to help the doctor determine how best to meet patient needs and engage them in their own care using a variety of tools, processes, and personnel as appropriate. PPCs maintain knowledge of care management, behavioral health, and chronic disease self-management resources available to patients and facilitates patients' adoption of these services, and then makes certain the gaps in care are closed. The PPC plays an integral role in promoting access to appropriate care, including transitional care services for vulnerable patients recently discharged from the hospital or ED. The PPC maintains access to and proficiency in programs including Epic patient registries and CRISP.
Essential Job Duties:
- Monitor and validate patient attribution to the practice and the care teams within the practice (known as empanelment).
- Ensure patients identified as increased risk and likely to benefit receive targeted, proactive, relationship-based (longitudinal) care management.
- Ensure patients receive a follow-up interaction from the practice within one week for ED discharges and two business days for hospital discharges.
- Ensure targeted patients who have received follow-up after ED, hospital discharge, or other triggering events receive short-term (episodic) care management.
- Ensure coordinated referral management for patients seeking care from high-volume and/or high-cost specialists as well as EDs and hospitals.
- Contribute to a positive experience for patients and families through courteous telephone interactions and interview activities, accurate and expeditious routing, as well as referral to appropriate clinical staff when necessary.
- Recognize and report data inconsistencies to appropriate practice personnel, and facilitate appropriate data capture and reporting methodologies
- Contribute to teamwork within and between departments. Regularly participate in meetings with coworkers and practice staff. Provide and receive constructive ideas, suggestions and feedback in a positive manner. Work collaboratively with co-workers to effectively resolve issues that impact departmental or hospital operations.
- Monitor and collaborate with practice to improve performance on key outcomes, including cost of care, electronic clinical quality measures, beneficiary experience, and utilization measures.
- Identify patient social and behavioral health needs, consult with clinician, as appropriate provide warm hand offs to One Call Care Management, social work, care navigation, and behavioral health services.
The minimum level of education and experience for this position includes:
- Minimum of High School Diploma
- Completion of accredited medical assistant training program preferred.
- One year of experience in a medical office setting and use of electronic practice management and medical record system(s)
- Experience operating multi-line phone systems, fax machines, photocopiers, and PCs, as required by the medical practice.
- Experience with Microsoft Office.
- Strong customer service skills
- Basic math skills.
- Hands-on clinical patient care is not required.
Working Conditions, Equipment, Physical Demands:
There is reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.
Physical Demands -
The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.
The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.