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CCM Coordinator
Full Time + Benefits/PTO

Qualifications: High School Diploma; experience preferred: Community Health Worker Certificate (CHW), Medical Assistant or Certified Nursing Assistant Certificate (CNA) with one year of community health experience, or a minimum of 2 years of community health/outreach; computer skills, i.e. proficiency with Microsoft Office applications including Outlook, Word, Excel and PowerPoint, team-oriented, ability to work efficiently without close supervision, good prioritization and organization skills, great customer service/communication skills, must maintain confidentiality relating to MVHC personnel, patients and information that could result in proprietary damage to MVHC; must possess current valid California or Oregon Driver’s license and auto liability insurance. 


Requirements after hire:

  • Clean and Appropriate Attire

  • Scrubs are to be worn to any home visit

  • Current CPR Card

  • Current/Valid California or Oregon Driver’s License

  • Auto Liability Insurance

Summary:  The Care Coordinator will assist high-risk, complex clients to access needed health services and complementary social services.  The Care Coordinator will coordinate services and community support to achieve improved health outcomes for clients.  The Care Coordinator works with the Primary Care Provider (PCP) and Care Management Team to provide services to patients in the MVHC Chronic Care Management (CCM) Program. The care coordinator will participate in ongoing training and reviews and follow established workflows for CCM program participation.


Duties and Responsibilities:  Under the direction and supervision of the RN Case Manager(s) and CCM Project Manager, follow CCM workflows to coordinate initial intake to program services.  Ensure complete and accurate registration, including patient demographic and current insurance information.


Review daily CCM referrals, and address referrals timely. Maintain tracking and appropriate documentation on referrals to promote team awareness and ensure patient safety; contact patients to obtain program consent and review patients’ care plans, medical follow-up, and psychosocial needs.


Assemble information concerning patient's medical history and clinical referral needs; assess client needs and provide information and referral to other identified resources.


Patient navigation services to help patients access recommended ancillary services.  Assist patients in problem-solving potential issues related to the health care system, and financial or social barriers (e.g., request interpreters as appropriate, transportation services, or prescription assistance). Link individuals to application assistance for health coverage programs.


Assist in the timely scheduling of primary care and other medical appointments to support client health.  Track and follow up on appointments to determine completion. Coordinate with the Behavioral Health team, Pharmacist, and other interdisciplinary team members to ensure client needs are being addressed.


Assist patient in meeting individualized health goals, identifying potential problems/barriers, and coordinate logistics for health goal adherence.


Review hospital inpatient and ER reports for CCM program participants for follow-up.


Maintain a good working relationship with community health partners by working as a liaison with other agencies and the community.


Document all clinical support tasks to maintain complete information on patient’s progress, including documentation in MVHC EHR.


Participate in quality assurance activities to monitor and improve client service quality.


Support care transition from inpatient to home, maintaining communication with the patient and/or caregiver to ascertain patient progress and identify needs for additional services or appointments.


Assist with referrals for non-medical care, such as transportation, food delivery, and linkages to other community-based or social services as they are available to the patient.

Assist with determining program eligibility and enrollment assistance in third-party payer programs.


Record information in, and retrieve information from, the patient’s MVHC electronic health record. Ensure that the patient's primary care chart is up to date with information on all CCM services provided, including consults, hospitalizations, ER visits, and community organizations related to their health.


Support implementation of Remote Patient Monitoring services, working in conjunction with CCM Team members.


Contact review organizations and insurance companies to ensure prior approval requirements are met. Present necessary medical information such as history, diagnosis, and prognosis. Provide specific medical information to financial services to maximize reimbursement to the hospital and physicians.


Review details and expectations about CCM services with patients to ascertain patient satisfaction with services and areas needing improvement.


Track all required data elements and report regularly as required by CCM Project Manager. Some data tracking may be manually performed.


Maintain a trusting relationship with the assigned client population and serve as a direct means of contact for the patient to the CCM team.


Appropriately identify and escalate important patient updates, assessment results, and information to the CCM Nurse and/or PCP as needed when new information is presented.


Physical Requirements: Sitting, close eye work, standing, walking, bending/stooping, squatting/crouching, balancing, reaching, twisting/turning, pulling, lifting up to 30 pounds, speaking/hearing on phone and in person, reading, writing, repetitive motion of hands, fine and gross manipulation, up/down and side/side hand motion, exposure to infectious disease, exposure to public/staff/physicians, working with others, fast work pace, frequent change, frequent interruptions, independent problem solving, and travel by personal vehicle to other sites.

Customer Care: A core value of Mountain Valleys Health Centers’ is our dedication to high-quality customer care. As a Community Health Center, our patients are our vitality; therefore, every patient will be treated accordingly.

At MVHC a customer is defined as but not limited to a patient, vendor, contractor, granting agency, community business, and employee. Customers will be treated with the utmost dignity and respect regardless of their socio-economic status, insurance type, job position, and/or race, etc. Discrimination is unacceptable and is grounds for immediate termination.

Every employee of MVHC will adhere to the Accountability Measures outlined either at the onset of employment or at the date of this signed job description. Should these expectations not be upheld, the employee understands that disciplinary action will be taken which could lead to immediate termination.


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