About Job
- Outreach and engage patients whom are high risk, post-discharge, and/or requiring additional care management support, ensuring they have Primary Care Provider (PCP) follow up appointments scheduled and all care gaps are closed
- Collaborate with care team members and external vendors to support patient care (ie: receipt of durable medical equipment (DME) and home health services
- Request medical records from a variety of physicians and healthcare systems enabling the continuity of care for both PCPs and members of the interdisciplinary care team
- Outreach, screen and escalate patients to nursing and social work team members based on the unique needs of patients
- Assist nursing and social work team members with patient follow up, proving tools and resources at their direction
- Monitor stable patient populations at the direction of nursing and social work team members
- Address open care gaps with patients through collaborative relationships with patients, ensuring supporting adequate documentation is available with the patient’s medical record
- Coordinate with local community resources as needed to support both the physical and psychosocial needs of patients
- Collaborate with multi-disciplinary team members to provide best in class patient care and improved outcomes
- Participate in special initiatives at the direction of market leaders
- Achieving objectives by effectively managing multiple tasks at one time
- Maintaining an organized and systematic workflow that results in goals being met
- Flexibility in an ambiguous and dynamic environment, maintaining a positive and “can do” attitude
- A passion for changing the way healthcare is experienced for complex and/or disadvantaged patients and communities
- Demonstrated strength-based approach to collaborative problem solving
- Effective engagement of diverse populations (age, ethnic groups, socio-economic levels, etc.) with exhibited cultural sensitivity
- A willingness to learn on your own and take initiative
- Demonstrated honesty and following through on commitments
- The ability to problem-solve on the spot and identify issues that need escalated
- A low ego and humility; an ability to gain trust through good communication
- 3+ years of experience in a medical office or health care setting
- 2+ years working as a Medical Assistant (MA) or Community Health Worker (CHW)
- Comfort with technology including the Microsoft suite of products
- Prior experience using electronic health record including data capture, data mining and reporting
Professional Field



Patient Focus
Diagnoses
Avoidant Personality Disorder
Gender Dysphoria
Issues
Aging
Financial Stress/Debt
Minority Health
Pregnancy, Prenatal, Postpartum
Therapeutic Approach
Methodologies
ECT
Modalities
Individuals
Teletherapy/Virtual
Practice Specifics
Populations
Veterans
Racial Justice Allied
Settings
Faith-based organizations
Milieu
Research Facilities/Labs/Clinical Trials
Telehealth/Telemedicine
Home Health/In-home
Military
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