Job Description

Summary:

Works collaboratively with physicians, staff, and other health care professionals to provide care coordination across the health continuum for all assigned patients ensuring that safety, best practice, and high quality standards of care are maintained. Serves as a mentor, educator, and advocate for personal health and wellness.

Responsibilities:

• Assist patient in the comprehension of complex instructions and facilities conflict resolution. Demonstrates strong organizational skills, priority setting skills and has the ability to multi-task various competing tasks. Must be able to learn and apply large amount of technical and procedural information. Must be able to communicate effectively verbally and in writing.
• Interviews and assesses patients and/or family, caregivers, and/or legal representatives. Provides outreach to patients and families to ensure care coordination. Determines, prioritizes, provides and/or arranges for needed internal and external services. Obtains medical authorizations and scheduling primary care, specialist care, lab, and diagnostic testing appointments.
• To independently analyze processes, high- risk patient information, identify problems and trends, and develop effective solutions and strategies. Facilitates care plans, provide updates to the team, and documents efforts. Uses varies forms of communication methods including but not limited to face-to face, telehealth, email, and mail. Works closely with physicians and the multidisciplinary care management teams.
• May consult and/or train new staff, students, and interns. May serves as backup for the Medical Assistant in performing basic medical care and exams.
• Uploads and tracks patient records in Avality to ensure patient population health continuum is compliant based on HEDIS measurements.
• Assist with the identification, determination and need for systems, process workflows, equipment and supplies, such as: Remote Patient Monitoring Devices (BP machine) and Colorectal Cancer Screening Kits. Monitors usage and oversees proper working order of equipment and ensures adequate supplies.
• Delivers general and specialized education on preventive and chronic care conditions measures, including weight and stress management, risk prevention and reduction, and living with specific health conditions. Responsible for regulatory compliance of Healthcare Effectiveness Data and Information Set (HEDIS) measures which are monitored and reviewed quarterly to ensure care gap metrics are achieved. Work with physicians to reduce emergency room utilization for avoidable visits through outreach and providing alternative resources.
• Provides assessment and coaching to individuals to help them develop and achieve wellness goals, including personal empowerment, lifestyle changes, and behavior modification. Assesses for Social Determinants of Health and provides community resources to leverage social barriers.
• Generate/analyze patient reports that are reviewed by senior at patient re-cap meetings along with key business stakeholders (Physicians, Pharmacists, and Nurses).Adheres to CMS compliance regarding Medicaid/Medicare regulations. Ensures regulatory compliance.

Education and Certification Requirements:

Accredited Program: Medical Assistant (Required) BLS American Heart E-Card (BLS AHA ECARD) - American Heart Association (AMERICAN HEART), BLS Cert American Heart_non ecard (BLS AHA) - American Heart Association (AMERICAN HEART), BLS Certification Grace (BLS GRACE) - Employee Grace Period for Essential Credential (GRACE), BLS Cert Red Cross (BLS RC) - Red Cross (RED CROSS)

Required Work Experience: Graduate of an accredited Medical Assistant/ EMT program with one (1) year of experience.

Other Information: Employment in this position is contingent upon successful completion of a Level II Criminal History record check. New Hires have 6 months to obtain their BLS Certification.

Additional Education Info: or Emergency Medical Technician (EMT) program.

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