Responsible to collaborate with patients identified with vulnerabilities and potentially eligible for case management (e.g., post-hospitalization, un-controlled diabetics, multi-pharmacy) to assist them in developing and updating an individualized care plan. In addition, performing outreach to encourage adherence with evidenced based guidelines to improve the health of company’s overall population. This position will support patients and their families in self-management and behavior change.
- LPN/RN or Medical Assistant.
- One (1) year clinical experience.
- Bi-lingual English/Spanish preferred; must be able to read, write and speak English.
- Basic computer knowledge; MS Word and MS Excel, internet, document with Electronic Health Records and/or authorization system with minimal typing/spelling errors, send e-faxes and email.
- Strong people skill, independent decision making and customer service oriented.
- Knowledge of medical terms, ICD10 and CPT codes.
- Registered Nurse License preferred
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Promote timely access to appropriate care.
- Increase utilization of preventative care.
- Reduce emergency room utilization and hospital readmissions.
- Increase comprehension through culturally and linguistically appropriate education.
- Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s).
- Increase continuity of care by managing relationships with tertiary care providers, transitions-in- care, and referrals.
- Increase patients’ ability for self-management and shared decision-making, using patient coaching and motivational interviewing.
- Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs.
- Promotes and reinforces patient centered medical home concepts with patients and staff.
- Assists with the development, revision, and coordination of the Plan of Care through collaboration. with the multidisciplinary treatment team to meet the patients’ needs effectively and efficiently.
- Develops short term and long term strategies in the development of expected patient outcomes; collects data through patient tracking in order to measure outcomes.
- Works collaboratively with provider(s) and other staff to ensure the delivery of quality care to patients to ensure best patient outcome.
- Assesses, plans, implements, coordinates, and evaluates the effectiveness of the patient programs.
- Collects data through patient tracking in order to facilitate patient outcome/population health data collection and analysis.
- Serves as a resource contact and information/education source to patients, families, providers, and/or staff.