JOB SUMMARY AND SCOPE
Assists patients with chronic conditions in navigating and accessing all levels of services, including quality care, health education and social services both in the physician practices and in the community.
ESSENTIAL JOB FUNCTIONS
- Assures that care is patient-centered and that patient and family members are informed about the plan of care and are involved in decision-making about that care.
- Develops care plans that prevent disease exacerbation, improve outcomes, increases patient engagement in self-care, disease risk status, and minimize hospital and ER utilization.
- Review patient data in EMR determined by the criteria set forth by ACO and quality initiatives.
- Enters data into and maintains disease registry, including regular database reporting.
- Maintains a registry of highest risk patients with documented completion of measures and interventions.
- Provides guidance to patients on available services and self management.
- Provides patients with health education and supportive services within and outside of the physician practice, including the facilitation of referrals.
- Follow up on care and ensure that patients are receiving appropriate care.
- Provides administrative support to program development as needed to implement chronic care programs, such as obtaining data, patient and provider feedback.
- Developing/managing care coordination systems that support referral, test completion and report receipt, and an integrated plan of care with specialists and other providers across the continuum.
- Triages high risk patients to identify the highest risk patients based on disease severity, self-care limitations, lack of family support, severe socioeconomic factors and health care utilization trends.
- Assists patients with scheduling for health education and chronic care services.
- Management of patients identified as high risk.
- Training of office staff in the coordination of care with specialists and other providers across the continuum.
- Maintains positive working relationships with all departments to enhance departmental cohesion.
- Demonstrates problem-solving skills.
- Follows through on problems that may hinder the delivery of patient care.
- Collaborates effectively with people at all levels.
- Maintains compliance with all hospital policies as well as compliance with all State, Federal and CMS policies of licensing and certification.
- Demonstrate a clear understanding of, and commitment to, the hospital’s mission, vision and values as well as the service excellence standards while completing all tasks and responsibilities.
- Provides coverage for other DECH physician offices when necessary.
- Seeks out needed information by staying informed and involved by attending meetings, reading memos, policies, meeting minutes, newsletters, email and other appropriate information in a timely manner.
- Reliable attendance and punctuality, including observing appropriate break times and extending a scheduled shift when necessary to meet patient demands (or assists in finding cover if unable to extend a particular day’s schedule).
- Performs duties in a safe manner, in compliance with all safety policies and procedures.
- Complies with the Down East Community Code of Conduct.
- Other duties, as assigned, that are relevant to the position and department.
*DECH is an equal opportunity employer.
Requirements
MINIMUM REQUIREMENTS
- RN, State of Maine License
- Proficient in computer technology, telephone communication, Microsoft Office (Word, Excel and Outlook)
- Experience in physician practice setting preferred.
- Current BCLS.
PHYSICAL EFFORT AND ENVIRONMENT
Moderate: Occasionally lifts up to 25 pounds independently. Occasionally pushes/pulls 100 pounds. Stands or walks often. Office environment/exam rooms.
EXPOSURE RISK
Exposure Category I: Employee at risk for exposure to blood borne pathogens.
QUALITY IMPROVEMENT
- Maintains current knowledge of the hospital-wide Quality Improvement Program.
- Collaborates with management to improve the effectiveness of the department through the Quality Improvement plans and processes.
- Participates in the departmental and hospital-wide Quality Improvement activities as directed by the manager.
COMPLIANCE
- Adheres to the federal, state, and local statutes and regulations.
- Adheres to the Compliance Program policies and procedures of Down East Community.
- Adheres to all Privacy and Security policies and procedures of Down East Community.
- Communicates any concern related to compliance issues to manager of department or Compliance Officer.
- Communicates any concern related to confidentiality issues to the Privacy Officer.