Legacy Community Health is a premium, Federally Qualified Health Center (FQHC) that provides comprehensive care to community members regardless of their ability to pay. Our goal is to treat the entire patient while improving their overall wellness and quality of life, in addition to providing free pregnancy tests, HIV/AIDS screening. At Legacy, we empower patients to lead better lives by promoting healthy behaviors and offering resources such as literacy classes, family planning services, and nutrition and weight management information.
Our roots began in 1981 as the Montrose Clinic, with specialization in HIV education, testing, and treatment. Since then, the agency has expanded to 10 clinics in Houston, one in Baytown, two in Beaumont, and one in Deer Park with extensive services that include: Adult primary care, HIV/AIDS care, pediatrics, OB/GYN and maternity, dental, vision and behavioral health. We also service students within KIPP and YES Prep schools. Legacy is committed to driving healthy change in our communities.
Job Description
Directs and supervises the delivery of clinical care coordination for all age groups across Legacy Community Health’s sites. Leads the Care Coordination Team of RN Care Coordinators and supports Care Team Assistants (CTA) in the assessment, planning, implementation, monitoring and evaluation of options and services required to meet the health needs of a panel of designated patients within high-risk groups. Responsible for the ongoing development, coordination and implementation of care management initiatives to support Legacy’s value-based agreements with multiple payor groups.
Essential Functions
- Serve as the subject matter expert for care coordination efforts within the agency
- Direct the RN Care Coordinators and CTAs to drive care coordination initiatives across all Legacy sites to include but not limited to:
- Pre-visit planning
- Gaps in care
- Referrals to specialists
- Hospitalizations and transitions of care
- Ancillary testing
- Acquisition of durable medical equipment and other enabling service
- Ensure department knowledge of and compliance with all applicable local, state, and federal policies, laws and regulations pertinent to care coordination
- Work with key members of the leadership team to collaboratively establish metrics aimed at meeting the needs of value-based agreements with affiliated MCOs and other payors
- Develop programs that support agency efforts to drive optimal health outcomes for targeted high-risk patient groups
- Collaborate with internal stakeholders to ensure seamless care coordination delivery across various agency departments i.e., Referral and Prevention teams, etc.
- Partner with the multidisciplinary provider team to develop innovative and evidence-based coordination approaches
- Work with the IT team to develop documentation in the EHR that supports efficient extraction of key data elements to aid in goal monitoring
- Develop expertise in the use of Legacy’s population health platform
- Create reports and dashboards that effectively communicate performance to operational and clinical leaders and stakeholders
- Make recommendations on new programs and services to enhance care coordination efforts
- Support the ongoing education and development of the Care Coordination team in the their efforts to actively manage care coordination for assigned panels of high-risk patients
- Monitor and manage employee performance and foster interdepartmental communication and education regarding care coordination activities and roles
- Establish and maintain effective working relationships with community service organizations and public agencies to ensure the care coordination team members offer all appropriate resources to patients and families
- Advocate on behalf of patients and families to facilitate resources with external partners
- Work with the care coordination team to identify barriers and resulting opportunities for intervention
- Ensure processes are in place that allow for a smooth transition of care for patients treated in a facility (inpatient or emergency department)
- Attend all required safety training programs and is knowledgeable of his/her responsibilities related to general safety, department/service safety, and specific job–related hazards
- Adhere to Legacy’s exposure control and blood-borne/airborne pathogens plans
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Education & Training Requirements
- A minimum of Bachelor’s Degree required
- Active license in the State of Texas as Registered Nurse, Required
- Master’s Degree preferred
- Case Management certification preferred
Work Experience
- Registered nurse with a minimum of 5 years of experience; 3 years leadership experience required with a proven track record of managing others in a hospital or clinic setting
- Must be detail-oriented and possess strong leadership qualities and initiative
- Strong interpersonal and conflict-resolution skill
- Exceptional written and verbal communication abilities
- Experience in Primary Care is highly desirable; home care clinical experience preferred
- Support practice mission and goals
- Bilingual Spanish preferred
Benefits
- 9 Holiday + 1 Floating Holiday
- PTO
- 403b Retirement Plan
- Medical / Vision / Dental (if eligible)
