POSITION SUMMARY
Works in collaboration and continuous partnership with chronically ill or “high risk” patients and their family/caregivers, clinic/hospital/specialty providers and staff, and community resources in a team approach to: 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, increase continuity of care by managing relationships, increase patients ability to for self-management and shared decision-making, provide assistance with medication refill requests and prior authorizations, connect patients to relevant community resources with the goal of enhancing patient health and well being.
It is expected that the employee demonstrate behavior consistent with the Core Values and support the strategic plan and the goals and direction of the Performance Improvement Plan.
EDUCATION/TRAINING EXPERIENCE
- Bachelor's degree or equivalent
- Three to five years in clinical or community resource settings; care coordination and/or case management experience desired
- Bilingual preferred
LICENSES/CERTIFICATIONS
- Clinical license preferred (i.e. RN, LVN, LPC, LMSW)
THE ESSENTIAL DUTIES OF THE POSITION
- Develop and implement a system for identifying and prioritizing continued care needs for Clarity patients, including identification and management of high risk patients
- Assist patients through the health care system by acting as patient advocate and navigator
- Educate patients/caregiver using “teach back” skills
- Conduct Post-Discharge phone calls within 48-72 hours to reinforce Discharge Plan
- Facilitate patient access to appropriate medical and specialty providers
- Coordinate continuity of patient care within Clarity system of care and with external providers to promote quality health outcomes and efficiently manage resources
- Communicate and coordinate effectively with, and is responsive to, internal/external providers (e.g., Clinical Staff, Medical Staff, and community providers)
- Promotes clear communication amongst care teams and treating clinicians by communicating care plans
- Support patient education and self management of disease
- Assists with identification of “high risk” patients, and add these to patient registry Participates in clinical team meetings and quality improvement initiatives
- Facilitate and attend meetings between patient, family, care team, payor, and community resources, as needed
EDUCATION/TRAINING EXPERIENCE
- Bachelor's degree or equivalent
- Three to five years in clinical or community resource settings; care coordination and/or case management experience desired
- Bilingual preferred
