Why work for Ampla Health?   25550

Ampla Health provides the individuals and communities we serve with high quality, comprehensive, community health care that is accessible to all and culturally and linguistically appropriate.

• Great Benefits including Medical, Dental, and Vision
• 4 weeks paid time off to start.
• 9 paid holidays
• 401k and profit sharing
• Full time, Monday to Friday
• Great work/home life balance

Ampla Health is seeking a Care Coordinator to support high-risk patients transitioning from hospital or emergency care. This role focuses on improving health outcomes by providing timely follow-ups, medication support, and personalized care planning.

Key Responsibilities:

• Manage a caseload of 150+ high-risk patients.

• Contact patients within 1–2 business days post-discharge.

• Coordinate timely primary care appointments.

• Assist with medication adherence and reconciliation.

• Document outreach and patient progress in the EHR.

• Collaborate with providers and support services.

Qualifications:

• Experience in care coordination, case management, or similar healthcare role.

• Strong communication and organizational skills.

• Proficiency with EHR systems preferred.

• Bilingual a plus (Spanish, Punjabi, or Hmong).

Why Ampla Health?

• Mission-driven team focused on patient-centered care.

• Opportunities for professional growth and development.

• Competitive benefits package.

GENERAL PURPOSE:

Under the supervision of the Care Coordination Nursing Supervisor, this position is responsible for providing care coordination to high-risk patients at Ampla Health. Care Coordinators are responsible for getting patients in to see their primary care physician within 3-7 days of hospital discharge, providing health education and supporting patients in establishing and achieving care and treatment goals.

MAIN RESPONSIBILITIES AND DUTIES:

1. Maintains at a minimum a caseload of at least 150 high-risk patients who were admitted or discharged from the ED or hospital.
2. Conducts daily outreach to assigned panel of patients within 1-2 business days of notification to Ampla Health of patient hospital discharge.
3. Actively enrolls all eligible patients into the Transitions of Care Program.
4. Secures patient discharge instructions and uploads to patient chart.
5. Uses the Ideal Transitions of Care Framework for coordinating care for high risk patients.
6. Provides medication adherence support through facilitation, patient education, and service linkages.
7. Performs quality control for post discharge medication reconciliation by PCP.
8. Conducts patient assessments including but not limited to chronic disease and social needs screenings.
9. Assists patients in securing medications, understanding instructions, securing appointments, and accessing a variety of clinical and social support services.
10. Assists patients in establishing and achieving care and treatment goals through a documented care plan.
11. Coordinates with Ampla primary care and other departments to achieve patient centered care and optimize patient communication and care.
12. Assists with referring patients to the Chronic Care Phamily Program
13. Maintains an accurate record of outreach, communications, patient needs, and services.
14. Works to achieve TOC program metrics as detailed to Table 1, below.
15. Supports Ampla Health’s mission by providing superior customer service and respecting patients.
16. Strengthens clinical and quality team work and rapport through strong work ethic and individual accountability.
17. Maintains professional growth by attending trainings, staff meetings, and required in-services as necessary.
18. Treats patients with empathy and respect and conduct oneself in a professional manner.
19. Complies with organizational guidelines and health care laws and regulations.
20. Other duties as assigned by supervisor.

TABLE 1: AMPLA HEALTH TRANSITIONS OF CARE PROGRAM METRICS

QUALITIES & CHARACTERISTICS

1. Maintains a professional relationship and positives attitude with co-workers, the public, patients and all Ampla Health’s staff, Board of Directors and vendors
2. Maintains the highest professional ethics and is honest in dealing with people; is a model for all employees through their actions
3. Strives to learn more and is receptive to learning different ways of doing things
4. Displays enthusiasm toward the work and the mission of Ampla Health
5. Ability to work in a fast-paced, patient service-oriented environment

PROFESSIONAL KNOWLEDGE, SKILLS & ABILITIES:

1. High School Diploma
2. Completion of Medical Assistant
3. Strong problem solver
4. Possesses outstanding interpersonal skills, including excellent written and verbal skills
5. Ability to connect and engage patients in person and over the phone
6. Demonstrates ability to promote quality improvement through development and maintenance of standards
7. Sensitive to the needs of the cultures represented in the Ampla Health patient population
8. Demonstrates clear knowledge of Ampla Health’s clinic structure, standards, procedures, and protocols

COMMUNICATIONS SKILLS:

1. Must have neat and legible handwriting
2. Must be able to interact with patients courteously and calmly
3. Ability to communicate well with the public

WORKING CONDITIONS & PHYSICAL REQUIREMENTS:

Works will with patients in a generally comfortable environment office. Employees must possess the following physical requirements:

1. Must be in good health and able to lift up to 40 lbs
2. Must be able to hear staff on the telephone and those who are served in person, and speak clearly to communicate information to clients and staff
3. Ability to operate standard office equipment such as a computer, telephone, fax machine, copier, etc.
4. Must be able to reach above the shoulder level to work, bend, squat and sit, stand, stoop, crouch, reach, kneel, twist and turning