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Providence Health & Services Clinical Coordinator in Santa Monica, California


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Providence is calling a Coordinator Clinical Care (Full time/Day Shift) at our Providence Saint Johns Medical Foundation location in Santa Monica, CA.

We are looking for a Coordinator Clinical Care who will identify high risk patients and help coordinate resources to facilitate care, improve health outcomes, and to reduce avoidable hospitalizations and re-admissions. Ultimately to provide the best quality medical care available, while working toward a patient centered medical home, and to help ease our patients' way.

The MA Coordinator Clinical Care primary responsibility is to administer care coordination activities for the patients of the primary care practice. This will include monitoring care coordination processes and support primary clinical teams with these efforts. It will also include identifying the high acuity patient population and working more directly to ensure care coordination for this patient population. The MA Coordinator Clinical Care behaves in a professional manner, and consistently demonstrates and promotes the values of Providence Saint John's Medical Foundation (PSJMF). The Care Coordinator will work with the Site Supervisor, Practice Manager. and lead physician of the practice to develop this position to best serve the needs of the patient panel and the primary care teams.

In this position you will:

  • Perform job functions timely and efficiently utilizing knowledge of medical assistant training and skills:

  • Deliver upon the service expectations of both our patients and fellow staff members by listening to their needs; engaging in positive interactions; and following through on promises made in a thoughtful, efficient, timely and courteous manner so that their total outcome is better than expected.

  • Respect the dignity, confidentiality and privacy of patients.

  • Work in a safe manner, adhering to general safety precautions and standards. Report any unsafe conditions to their supervisor and/or the safety hotline.


  • Work with all clinical teams as a resource on care coordination of all patients of the practice, this would include the following:

  • Pre-visit planning workflow to ensure care completion prior to visit whenever possible Work with IT resources to facilitate registry reporting at the site.

  • Serve as a resource to clinical staff and providers to meet quality goals by reaching out to patients.

  • Maintain strict confidentiality; follow HIPAA regulations.

  • Treat staff, physicians, NPs/PAs, visitors, patients and families with dignity and respect Participates in professional development activities.

  • Involving the patients in activities to improve their health (patient engagement); Educating the patient about self-management tasks they can undertake to gain greater control of their health status.

  • Develop and maintain a patient list with the primary care physician, case managers, practice managers, hospital discharge planners, and the hospitalist team to identify and track patients with chronic conditions at risk for decompensation or re-admission.

  • Work with the care team to determine what actions are required in coordinating complex patient care. This will include:

  • Contact patients and/or families to review the condition, and assess need for appointments

  • Schedule appointments in the system and work with the office staff when necessary to fit the patient into the physician schedule.

  • Arrange transportation when necessary.

  • Expedite and help process authorizations and referrals for necessary services (DME, home health, consultations with specialists, procedures, etc.)

  • Coordinate appointments with other services and practices and advise patient accordingly.

  • Follow up with patients after such appointments.

  • Gather test results for the ancillary services and other medical information (when not available in Epic) and present it to the physician for evaluation before the patient’s follow up appointments, post-hospital

  • Document in the electronic record all conversations with patients, family, or surrogates, and information as necessary for tracking.

  • Use risk stratification tools to identify care-gaps

  • Work with the team to address and complete care gaps. Document, and update the HMP.

  • Provide education and guidance to the patient as directed and supervised by the physician, and consistent with the CCC’s training.

  • Access the expertise of the PharmD in Medication Reconciliation, and set up appointments with the Pharmacist as needed for patient care and education, or as requested by physicians.

  • Assist patient in accessing insurance information, DME, prescriptions,

  • Assist in completion and gathering of POLST and ADVANCED DIRECTIVE forms

  • Actively manage assigned panel of chronic care patients (high acuity):

  • Develop relationship with patient as on integral member of team by phone, portal, etc.

  • Provide follow-up contact with patient as indicated to ensure compliance with recommendations- medications, lob/x-ray, specialist visits, PCP visits, dieticians, CDE, etc.

  • Anticipate the needs of this patient population, seeing that necessary documentation and pre­-visit planning is completed or requested before patient visit;

  • Collaborate with the patient, physician, and other core team members in assessing the patient's progress toward individual health core goals;

  • Communicate barriers to physician when patient has not met treatments goals, is not following treatment plan of core, or has not kept important appointments;

  • Assist with procurement, and adoption of patient self-management educational resources used by the primary clinical teams.

  • Manage many aspects of the patient's core: referrals to specialists, hospitalizations, ER visits, ancillary testing, and other enabling services.

  • Assist patients in setting SMART goals for self -management, teaching them how to do self­ management tasks and report abnormal findings to their physician team.


  • Ensure safe and effective care while the patient transitions in the core continuum. Serves as the bridge between consulting physicians, hospitals, ER and other frequently used healthcare resources and the patient and/or family:

  • Collaborate with physician, NP/PAs, clinical and non-clinical staff to identify appropriate patients for core transition services.

  • Prioritize referrals and activities according to protocols (staff will send copy to coordinator).

  • Help coordinate consult/referral, hospital/ER, community resource follow-up for the practice.

  • Coordinate clinical follow-up with patients per protocol when indicated.

  • Provide information and guidance to patients and/or family regarding effective core transitions and enhanced patient-core team communication.

  • Maintain accurate and timely documentation:

  • Obtain daily admission and discharge lists from St. John’s and SM-UCLA.

  • Initiate contact and transitional care management to meet criteria per protocols.

  • Set up the 7 or 14 day follow up visit as clinically indicated.

  • Assist physician in completing checklist of requirements to bill for the transitional care management.

  • Participate in the huddles, phone calls and team meetings as time and physical location allows.

  • Perform back office skills -- vital signs, BP, weight, history taking, 1M/Sub Q injections, minor procedures, sterile case set-up, assist with minor surgeries, autoclaving, EKG, treadmill, PFTs, pulse oximetry, Accu check, surgery scheduling, make and verify appointments, call back authorized pharmacy refill prescriptions, ICD-9, CPT coding.

  • Administer routine immunizations, injections and skin tests following verification of dosages and with appropriate documentation.

  • Perform blood pressure checks. Informs practitioner of results. Assists with emergencies as needed.

  • Provide accurate, complete, legible and timely documentation of all procedures performed in the medical record.

  • Demonstrate a thorough knowledge of procedures included in the Medical Assistant scope of practice.

  • Communicate all test results, patient concerns and changes in the patient's condition to the physician or registered nurse.

  • Follow correct procedures for handling and disposing of biohazardous infectious waste.

  • Perform daily and weekly environmental cleaning and equipment quality control and maintenance.

  • Order and maintain current inventories of medication and supplies

  • Check for outdated medication on a monthly basis.

  • Comply with all applicable infection control and safety procedures.

  • Demonstrate awareness of current state, federal and local laws.

  • Use appropriate reporting mechanisms as required by state laws.

  • Provide open and timely communication with patients, families and their significant others:

  • Provide sufficient information to allow patients and their significant others to participate in the patient's care.

  • Provide educational resources to the patient/family as appropriate as instructed by the physician or registered nurse.

  • Demonstrate commitment to education and sharing of knowledge:

  • Assist in the orientation of new personnel to the office.

  • Obtain ongoing education consistent with level and area of practice.

  • Maintain current American Heart Association BLS for Healthcare Providers and other appropriate certifications.


Required qualifications for this position include:

  • Graduate of school for medical assistants and certificate or a diploma/certificate from the military in Medical Specialist Course.

  • 2 years experience in directed patient care at MA level or greater.

  • Knowledge of UR/QA requirements.

  • Knowledge of medical practice and care of patients.

  • Knowledge of examinations, diagnostic and treatment procedures.

  • Knowledge of medical equipment and instruments.

  • Knowledge of common safety hazards.

  • Ability to use good judgment and critical thinking skills; ability to identify and resolve problems.

  • Ability to apply guidelines and protocols.

  • Ability to establish and maintain effective working relationships with patients, families, medical staff, and co-workers.

  • Ability to interact professional and advocate vigorously with specialty offices on behalf of our patients.

  • Ability to schedule appointments within the Epic platform for patient follow up.

  • Ability to work independently, while collaborating with other team members.

  • Ability to self-motivate, prioritize, and is willing to invest in a change process to improve efficiencies. Excellent written, verbal and listening communications skills.

  • Proficient computer skills - data entry, retrieval and report generation.

  • Ability to work with a diverse patients/family population.

  • Current American Heart Association BLS for Health Care Providers.

About the location you will serve:

Providence Health & Services is further developing its physician integration strategy. As part of this growth, Providence Saint John’s Medical Foundation came into flourishing. Saint John’s Medical Foundation is an integrated, not-for-profit network of medical clinics and affiliated services, servicing the greater Santa Monica and Los Angeles area. The Foundation is expected to continue to grow in the next several years, bringing with it facilities, staff and physician growth to support that objective.

We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

Schedule: Full-time

Shift: Day

Job Category: Community Service

Location: California-Santa Monica

Req ID: 307852