- Establishes close relationships with and serves as primary point of contact for patients.
- Call patients on a regular basis
- Communicates with ED Care Team members (Recovery Support specialist, physicians, and other health care providers) to facilitate patient care.
- Carries out tasks to execute the medical and support service plans including guiding patients to appointments and accompanying them when necessary.
- Ensures that medication adherence issues are addressed.
- Provides education and coaching for specific population needs as required by the program or department.
- Acts as the primary liaison with medical providers to ensure patient adherence.
- Delivers monthly or weekly health education encounters.
- Coordinates logistics for plan adherence such as appointment reminders, arranging transportation, scheduling appointments.
- Documents all patient encounters and enters all data into web-based system.
- Performs other tasks as required.
- Identifies resources for patients to overcome barriers to care, such as transportation, housing, and food.
- Remains aware of current services offered by service providers, such as mental health, housing, and employment assistance.
- Maintains strict confidentiality in accordance with state and agency policies.
- Organizational duties:
- Maintains documentation of all patient encounters and complete reporting requirements according to organization standards
- Tracks patient information, schedules, files, and forms in a confidential manner
- Tracks patient attendance at medical appointments and patient navigation sessions and initiates outreach and missed appointment procedures, as necessary.
- Attends and represents the organization at professional conferences, in-service trainings, and meetings at the request of or with the approval of Clinical supervisor
- Physical demands associated with office work
- Evening and some weekend work required; other duties as assigned
Personal characteristics and skills:- Commitment to the mission of care coordination
- Passionate, trustworthy, and empathetic when working with patients
- Ability to build relationships with different types of people, including patients, organization members, and health care providers
- Good communication and interpersonal skills and ability to speak concisely to patients and ED Care Team members
- Organized with confidential patient material and appointment tracking
- Flexible and adaptable in response to changing patient and health care providers' needs
Minimum high school degree or some college education- Strong understanding of cultural competency with the target population
- Bilingual (English/Spanish) preferred
- Computer literacy a must
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Description
Responsibilities:Office-based direct care to all discharged patients: