Job Type Full-time Description ROLE AND RESPONSIBILITIES:
- Use Transitional Care Management processes to assure quality care is delivered to the PHC's patients, the patients' families, and the patients' caregivers in the most efficient and effective manner across the healthcare continuum.
- Engage patients, patients' families, and their caregivers in a manner that is culturally and linguistically appropriate to the patient and caregiver.
- Serves as a liaison between the provider and patient between inpatient stays and between care team and patient within support referrals.
- Identifies and addresses barriers to care that might keep the patient from receiving timely and appropriate treatment as well as assists with identifying community resources and/or support programs.
- Ensures quality patient care by adhering to the policies of PHC, involving patients and their families in identifying their needs, creating a plan to meet those needs, and effectively communicating the plan across the continuum of care.
- Trained in motivational interviewing to provide gateway introduction into chronic care management.
- Assist the care team in quality improvement projects.
- Participate, as directed, in continuing professional growth through attendance at workshops and professional in-services and through individual research and reading, to include communication skills.
- Attend and participate in organized functions of PHC and perform administrative functions as necessary.
- Demonstrate personal responsibility and respect for patients, patients' families, and co-workers in professional appearance.
- Demonstrate flexibility, enthusiasm, and willingness to cooperate while working with other in multi-disciplinary teams.
- Other duties as assigned.
Requirements QUALIFICATIONS
- High School Diploma
- CMA/CCMA/RMA or CNA with ability to obtain CMA/CCMA within 1 year
KNOWLEDGE AND SKILL REQUIREMENTS:
- Self-motivated, dependable, strong work ethic with a desire to learn.
- Experience with computer applications with proficient excel abilities.
- Ability to work effectively in a team environment.
- Knowledgeable in the various clinical and non-clinical workflows in a medical practice.
- Familiarity with medical terminology.
- Ability to apply critical thinking skills and make sound judgments both while performing daily responsibilities and throughout the patient's continuum of care.
- Ability to work independently and successfully in a fast-paced, stressful environment.
- Ability to work with a registry and an electronic health record.
- Empathy, mental alertness, precision, analytical problem-solving abilities, communication skills, focus, and initiative.
- Effective oral and written communication skills.
- Excellent interpersonal skills reflecting clarity and diplomacy and the ability to communicate accurately and effectively with all levels of staff and management.
ENVIRONMENTAL/WORKING CONDITIONS:
- Talking, hearing, repetitive motions and close visual acuity associated with a normal office environment.
- Potential for a variety of exposure to additional work settings to include clinical/medical office, patient's home, and/or a community-based environment.
- Dedicated home office space for remote work flexibility, as role is assigned/directed by a supervisor. If directed for remote work, the home office space must be of low distraction, HIPAA compliant, and supported by a reliable internet service to support system applications.
PHYSICAL/MENTAL DEMANDS:
- Standing, sitting for long periods while doing computer input and making phone calls.
- Must have ability to bend, stoop, twist and work with computer equipment.
- Stress involved in working with patients with multiple co-morbidities and multiple assignments.