Emphasis of the position is on assisting the health center staff in promoting patient health through education, case management, and population health management using patient registries. Provides outreach for health/wellness and disease management. Supports healthy lifestyle choices that will reduce long term effects of illness and improve quality of life.
Performs other clinically-based activities that involve coordination of care between members, health center staff, and community health organizations. Collects clinical data and enters information into electronic health record for tracking and metric purposes.
- Provide health-coaching and consultation services to patients, within state licensure scope of practice requirements. Conducts health risk assessments, introduces case management services, identifies and addresses barriers to treatment adherence and educates members about healthy lifestyle choices within state licensure of practice requirements
- Collaborates with patients to establish goals and provides ongoing support to members such that they strive to make and sustain healthy lifestyle choices. Provides participants with educational materials.
- Collaborates with primary care health center staff and provider as well as medical home and other healthcare professionals to obtain specific and current health information in regards to member’s plan of care.
- Reviews data from variety of sources to assist in identifying co-morbid conditions, hospitalizations, prescriptions and other factors that could impact the health of the patient. Uses data to identify problems, set goals, plan interventions, and determine overall health status within the scope of practice.
- Assists in care coordination which may include obtaining test and referral results and communication with various entities including but not limited to community organizations, health plans, health facilities and specialists.
- Proactively address patient needs through population health management.
- Creates and manages patient registries that include care considerations for chronic disease management and preventive care.
- Effectively communicates with all patients with specific attention to the vulnerable patient population.
- Document all activities as outlined in the Valley Health Policy Manual
- Assist the operations team in collecting clinical data for NCQA accreditation, meaningful use, and insurance sponsored PCMH projects.
- Other duties as assigned. Working Conditions:
- Work is sedentary in nature; however, the ability to stand and/or walk for periods of one hour intervals; stooping, bending, reaching, lifting approximately 25 pounds is required.
- Work is repetitive in nature and requires concentration and constant technical attention to accuracy and detail for extended periods of time.
- Conveys a professional and positive image and attitude of regarding the health center and organization.
- Develops good rapport with colleagues, patients and their families.
- High School Diploma or Equivalent; degree in Medical Assisting or Nursing preferred.
- Must possess a working knowledge of Medicaid/Medicare, adult learning and behavior change principles, chronic illnesses, co-morbidities and disease management and community based resources.
- Skills include excellent verbal and written communication skills, telephonic interviewing skills, computer skills, and prioritization and organizational skills.
- Must be able to prioritize and target interventions designed to support long term behavioral change within state licensure scope of practice requirements 8 - 4:30 Monday through Friday