Job Description

• Excellent customer service skills. Ability to work with various departments within the hospital system as well as external resources.
• Provides education and counseling for individuals and groups with chronic disease as well as for preventive health under the direction of nursing, providers, site leadership and ambulatory administration

• Serves as the point of contact in transition of patient care from ED or hospital discharge back to primary care Documents education in the patients EMR.
• Performs the screening for provider review of behavioral health and substance use problems, including depression, alcohol abuse, substance abuse and smoking status using validated tool within the emr.

• Alerts nursing or provider about patient issues that may be identified during sessions via the EMR or in person documenting such.

• Proactively performs outreach to patient populations Identifies patients with gaps in care

• In collaboration with the health care team, identify patients that require follow up either regarding chronic health maintenance, preventive, no show or other, contact the patients and ocument the outcome of this intervention in the EMR.

• Schedule appointments for patients based on outreach activity or follow up interventions.

• Tracks and follows up on test results to ensure patient and caregiver take appropriate next steps as needed

• Tracks and follows up on test results to ensure patient and caregiver take appropriate next steps as needed

• Attend daily huddles with the health care team.

• Identify barriers to care and direct the patient to the appropriate source for assistance.

• Collect and maintain statistics regarding interventions with the patient and work with the appropriate source to create meaningful reports.

• Report health interventions and trends as required.
• Perform community health outreach as directed either to specific patients or at health outreach events

• Demonstrates excellent customer service, professionalism, sensitivity towards patients and coworkers.

• Work on special projects or health initiatives as assigned.

• Works with DSRIP team and PI to impact positive outcomes

• Excellent communication skills, able to effectively engage patients

• Works independently with guidelines provided and reports to Nurse Manager.
• Acts as an integral member of the health team

• Report on and works to continuously improve processes in conjunction with the ambulatory health team

• Acts as a liason and patient advocate to promote positive patient outcomes

• Recognizes the need for considerate team work and facilitates the concept with others

Formal Education and Job-Related Experience : This position requires a minimum formal education of High School Diploma or equivalent and a minimum of 3 years job-related experience.

Desired (not required) criteria include: Bachelor degree preferred. Experience in EMR preferred.

Comments : Health maintenance and outreach experience. Experience with population health management. Experience in health related field with direct patient contact/customer service. Excel, Word – ability to create tracking.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

Job Tags

Similar Jobs