Works in conjunction with the Care Coordinator and other members of the Primary Care Coordination team. Seeks to improve the health of patient populations, improve patient satisfaction and engagement, and strives to decrease healthcare cost.
*Assists the Care Coordination team with pre-visit planning which includes, but is not limited to; assures provider has access to lab results, referral progress notes, ER visits/consult notes, and other specialist consult reports.
*In collaboration with the Care Coordination team, develops and improves workflow and protocols for primary care to ensure a seamless transition for the patient.
*Provides outreach to patients as they transition through multiple healthcare settings. Provides assistance with care management activities, facilitates communication, helps to addresses barriers, and promotes optimal allocation of resources.
*Creates daily reports to identify patients hospitalized, discharged, and treated in the Emergency Department. Provides follow up communication to patients and Care Coordination team.
*Supports patients in an effort to make them successful while following their written plan of care. Encourages patient to use self-management tools as provided.
*Assists with scheduling follow-up visits with the patient’s primary care provider (PCP) or other care team member as needed.
*Provides information to patients and families regarding community resources, medication assistance, and other healthcare needs.
*Provides ongoing telephonic communication and assistance to patients who no longer are in need of high risk chronic care management from the Care Coordinator. Encourages assigned patients to continue following the care plan.
*Assists patients with scheduling, ordering lab work, and/or testing that may be needed for a chronic disease as defined in the clinic standard protocols.
*In collaboration with the Care Coordination and Quality teams, works to identify different panels of patient populations. Reviews reports related to chronic disease and high risk patients in an effort to assist in chronic care management.
*Works in conjunction with the Care Coordination team to ensure patients receive preventative care as determined by clinic protocol.
*Works toward continuously improving quality metrics and closing care gaps. Supports clinicians in achieving quality incentives
Recent experience in a primary care setting, medical office, or healthcare setting required.
Proven ability to work collaboratively with multidisciplinary medical home care teams required. Knowledge of professional practice standards, regulatory requirements, and systems operations required.
Current Certified Nursing Assistant (CNA), Certified Medical Assistant (CMA), or Licensed Practical Nurse (LPN) preferred.
Knowledgeable of healthcare quality programs including Medicare Access and CHIP Reauthorization Act (MACRA), Comprehensive Primary Care (CPC+), Merit Based Incentive Program (MIPS), Physician Quality Reporting System (PQRS), Value Based Payment Modifier (VBPM), Patient Centered Medical Home (PCMH) and Patient Centered Specialty Practice (PCSP) preferred.
Current BLS certification.
Possess and maintain computer skills to include working knowledge of Word, Outlook, Excel, and the ability to learn other software as needed. Experience and knowledge of electronic health records and data analytics preferred.
Must have strong organizational skills and attention to detail. Strong research and analysis skills highly preferred. Must successfully function in a fast-paced, service-oriented environment.
Ability to communicate effectively and maintain cooperative relationships with providers, staff members, patients and the medical community. Ability to employ tact, diplomacy and compassion with all types of people.