Responsibilities
Collaborate with our clinical care team, particularly under the guidance of RN Care Managers, to act as a patient advocate and facilitate their care needs.
Manage a caseload using various communication methods, including in-person, telephonic, and electronic means, ensuring effective coordination.
Build and maintain trusting relationships with patients, serving as the primary representative of our healthcare services.
Schedule and organize initial wellness exams and care management assessment meetings with our clinicians.
Facilitate connections between patients and necessary resources, including care team members, primary care physicians, specialists, and community services.
Engage in community involvement initiatives to enhance overall patient wellbeing.
Key Responsibilities Include
Following health management plans and goals under the guidance of healthcare professionals.
Documenting activities in the care coordination platform, ensuring comprehensive and accurate records.
Assisting patients in self-care needs, addressing language, cultural barriers, and coaching them to achieve personal and clinical goals.
Scheduling provider appointments and accompanying patients when necessary.
Supporting patients in accessing community and government-based services, including paperwork assistance.
Educating caregivers on symptom response plans and assisting with preventive monitoring.
Participating in integrated care team meetings and conducting telephonic outreach to encourage patient enrollment.
Qualifications
Required:
Experience working with populations such as Medicare, Medicaid, or Special Needs.
Previous roles as a Medical Assistant, Licensed Practical Nurse, Engagement Specialist, or Community Health Worker.
Strong communication skills, cultural awareness, and the ability to connect with individuals facing diverse challenges.
Willingness to travel within the assigned region and conduct home visits (50-75% same-day travel).
Preferred
Experience with chronic and behavioral health needs.
Success in multidisciplinary teamwork, engaging patients in healthy behavior changes, and navigating healthcare systems.
Familiarity with Electronic Medical Records and other documentation platforms.
Measures Of Success
Patient Engagement and Success.
Smooth Care Transitions.
Monthly Goal Attainment.
Reduced Hospital or ER Visits.
Employment Type: Full-Time
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