Job Description
Job Title: PCMH Coordinator & Chronic Care Manager
Department: FQHC Clinic
Supervisor: Quality Coordinator
FLSA Status: Non-Exempt
Prepared By: Human Resources
Prepared Date: February 23, 2024
Summary
Supporting the Mission and Core Values of Hoxie Medical Clinic, the individual in
this position works cooperatively with all staff members; serving each other, our
customers, and promoting a team effort and positive presence at all sites. The
Patient Centered Medical Home Coordinator (PCMH) will have the responsibility of
facilitating organizational changes consistent with the Chronic Care Model for
chronic care diseases and the selected model of management for clinical
operations. Will develop and facilitate programs that encourage health and
wellness, and prevent disease to help teach patients, the general public, and
caregivers how to make good health decisions, incorporate healthy activities into
their lives, and avoid harmful behaviors.
Essential Duties and Responsibilities include the following. Other duties may be
assigned.
1. PCMH Coordinator Duties
a. This person works with the Clinic Manager/Project Director,
administrative staff, Quality Coordinator/Nurse Manager, and other staff
throughout the organization to implement the chronic care model.
b. Provide educational programs and training for the staff to assist in better
understanding of PCMH and its objectives.
c. Assess, observe and implement daily operations changes in the clinical
setting to better support PCMH initiatives.
d. Will assist in promoting and improving the health outcomes of Hoxie
Medical Clinic patients and improving the clinical efficiency of Hoxie
Medical Clinic.
2. Community Educator Duties
a. Responsible for developing and facilitating health education programs
for the general public, as well as targeting at-risk populations, such as
diabetes patients, expectant mothers and heart patients. Preparing
presentations, conducting health screenings and patient outreach, and
serving as point of contact for patients.
b. Provide patients with information on their diagnosis and treatment, as
well as tips on staying healthy.
c. Assist in training medical staff on how to communicate with patients.
d. Assist in the creation of health-related materials to compliment current
initiatives and classes.
e. Collect data and other information needed to analyze the current
programs offered and future or current needs of the general public and
patient population served at HMC.
3. Chronic Care Manager Duties
a. Responsible for facilitating, organizing, and carrying out the CCM
services for patients.
b. Will work closely with clinical and managerial staff to sustain and/or
improve existing patient centered chronic care management programs
and initiatives.
c. Will work with the administrative staff, the quality coordinator/nurse
manager, and other staff throughout the organization to implement new
chronic care management programs and outreach.
Supervisory Responsibilities
No Supervisory Responsibilities
Competencies
To perform the job successfully, an individual is expected to abide by all SCHC policies
and procedures along with demonstrating the following competencies:
Analytical - Synthesizes complex or diverse information; collects and researches data;
uses intuition and experience to complement data.
Continuous Learning - Assesses own strengths and weaknesses; seeks feedback to
improve performance; pursues training and development opportunities; strives to
continuously build knowledge and skills; shares expertise with others.
Job Knowledge - Exhibits ability to learn and apply new skills; keeps abreast of current
developments; requires minimal supervision; displays understanding of how job relates
to others; uses resources effectively.
Use of Technology - Demonstrates required skills; adapts to new technologies;
troubleshoots technological problems; uses technology to increase productivity; keeps
technical skills up to date.
Problem Solving - Identifies and resolves problems in a timely manner; works well in
group problem solving situations; uses reason even when dealing with emotional
topics.
Customer Service - Responds promptly to customer needs; responds to requests for
service and assistance.
Communications - Expresses ideas and thoughts verbally; expresses ideas and
thoughts in written form; exhibits good listening and comprehension; keeps others
adequately informed; selects and uses appropriate communication methods.
Cooperation - Establishes and maintains effective relations; exhibits tact and
consideration; offers assistance and support to co-workers; works cooperatively in
group situations; works actively to resolve conflicts.
Teamwork - Gives and welcomes feedback; contributes to building a positive team
spirit; supports everyone's efforts to succeed.
Quality Management - Looks for ways to improve and promote quality; demonstrates
accuracy and thoroughness.
Diversity - Promotes a harassment-free environment.
Ethics - Upholds organizational values.
Adaptability - Adapts to changes in the work environment.
Dependability - Takes responsibility for own actions; completes tasks on time or
notifies appropriate person with an alternate plan.
Judgement - Exhibits sound and accurate judgment.
Planning/Organizing - Prioritizes and plans work activities; uses time efficiently.
Qualifications
To perform this job successfully, an individual must be able to perform each essential
duty satisfactorily. The requirements listed below are representative of the knowledge,
skill, and/or ability required. Reasonable accommodations may be made to enable
individuals with disabilities to perform the essential functions.
Education and/or Experience
Primary professional training in a medical health profession such as CNA, MA, or
nursing is preferred but not required.
3 years of professional experience in a clinic setting preferred but not required.
Previous experience with PCMH and requirements preferred but not required.
Language Skills
Ability to read and interpret documents such as safety rules, operating and
maintenance instructions, and procedure manuals. Ability to write routine reports and
correspondence. Ability to speak effectively before groups of customers or employees
of organization. Fluent in both English and Spanish languages preferred.
Mathematical Skills
Ability to add, subtract, multiply, and divide in all units of measure, using whole
numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent
and to draw and interpret bar graphs.
Reasoning Ability
Ability to apply common sense understanding to carry out instructions furnished in
written, oral, or diagram form. Ability to deal with problems involving several concrete
variables in standardized situations.
Computer Skills
Must be able to learn and utilize all computer programs and software programs needed
by the facility.
Physical Demands
The physical demands described here are representative of those that must be met by
an employee to successfully perform the essential functions of this job. Reasonable
accommodations may be made to enable individuals with disabilities to perform the
essential functions.
While performing the duties of this Job, the employee is regularly required to use
hands to finger, handle, or feel. The employee is frequently required to sit; reach with
hands and arms and talk or hear. The employee is occasionally required to stand;
walk; climb or balance; stoop, kneel, crouch, or crawl and taste or smell. The employee
must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up
to 25 pounds.
Work Environment
The work environment characteristics described here are representative of those an
employee encounters while performing the essential functions of this job. Reasonable
accommodations may be made to enable individuals with disabilities to perform the
essential functions.
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