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Engages a population of medically vulnerable or chronically ill patients in their care, assisting them through the process of working towards better health by providing support, encouragement and education
Communicates and maintains relationships with other members of the Care Management team to promote a lifelong, proactive partnership with patients to enhance and personalize management of health-related needs
Completes screenings on patients for social determinants of health needs and refers as appropriate
Communicates with patients and caregivers in person, by telephone and via electronic means
Utilizes Chronic Disease Management protocols, under the direction of clinical teammates
monitors patient-reported biometrics, medication adherence, reported challenges/barriers and promptly connects the patient with the appropriate resources, and/or notifies the patient's care team for additional follow-up
Provides customized, evidence-based patient education in a variety of areas, under the guidance of clinical teammates and based on the patient's readiness to change
includes but not limited to weight management/exercise, tobacco cessation, stress reduction and chronic disease self-management
Uses Motivational Interviewing skills to engage and assist patient/parent/family
Assists providers' offices/ medical home staff with member specific missed appointments through outreach and scheduling
Advocates and facilitates referrals to gain access to services and resources for patients, including patient assistance programs, community-based services and mental health support
Assists with the coordination of care across the care continuum and transitions of care (including home care, outpatient care, ER care, and hospital care) while maintaining strict patient confidentiality
Advocates to help those who frequently access inappropriate levels of care
Requirements:
Completion of an accredited Medical Assistant program or may have completed structured military training which is clinical in nature per DD214 in lieu of a formal medical assistant program or EMT
A High School Diploma or GED is required
Must possess excellent verbal and written communication skills
Must possess basic computer knowledge and ability to use Microsoft office applications
Strong organizational skills
Must have effective interpersonal skills
Must be able to respond quickly to changes in community and clinic settings
What we offer:
Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs