JOB PURPOSE OR MISSION: Implements and evaluates specialized organizational clinical programs while enhancing the quality-of-care delivery to patients through personalized navigation. Provides clinical consultation, care coordination and education to patients serving as a liaison to help remove patient barriers to care by identifying critical resources and facilitate the continuum of care. Performs all job duties for the age population served, as defined in the department’s scope of service.

JOB FUNCTIONS

ESSENTIAL JOB FUNCTIONS include, but are not limited to:

1. Implements and evaluates specialized organizational clinical programs while enhancing the quality-of-care delivery to patients through personalized navigation.

PERFORMANCE STANDARDS:

• ED Managed Care Incentive Payment (MCIP) Program quality strategy measures:

o Implement activities designed to address avoidable ED utilization and create improve patient health outcome.

• ED HIV/HCV Program quality strategy measures:

o Implement activities designed to address early detection of HIV/HCV positive patients and provide early linkage and treatment to reduce the spread in our community.

2. Provides clinical consultation, care coordination and education to patients serving as a liaison to help remove patient barriers to care by identifying critical resources and facilitate the continuum of care.

PERFORMANCE STANDARDS:

• Screens patients to determine appropriate level of care coordination interventions based on risk factors related to barriers that impact progression of care, transition of care, and readmissions.

• Assesses patient situation by collecting information from patient and family, professional and non-professional caregivers, employers (as appropriate), and health records to identify individual needs.

• Identifies related quality metrics to promote medical compliance.

• Recognizes and responds appropriately to risk factors and/or barriers to care.

• Outreach to community providers to address access to care issues.

• Educate providers and interdisciplinary staff annually related to program milestones.

• Serve as primary liaison between and among physicians, patients, families, payers, external case managers, post-acute providers, and interdisciplinary clinical team.

• Maintain appropriate documentation on each patient to include specific documentation of all planning, liaison, and coordination activities.

• Identify, organize, and secure the resources necessary to accomplish the goals set forth to help remove patient barriers.

• Facilitate the timely delivery of services to patients and families through effective management and utilization of available resources.

• Assertively manage resource utilization while appropriately navigating the patient's movement along the continuum of care.

3. Leverages internal and external resources to facilitate innovative approaches to move patients along the continuum of care.

PERFORMANCE STANDARDS:

• Promotes, maintains, and seeks opportunities to further improve collegial relationship with community agencies and other professional disciplines by participating in community activities and serving as patient advocate.

• Demonstrates skill in preparing written reports, progress notes and other material that is concise and well-constructed for ease of reading.

• Consults daily with program colleagues and assists where necessary to support program goals and achieve desired outcomes.

• Demonstrates knowledge of current program changes and initiatives to ensure program compliance.

4. Performs other duties as assigned.

EXPERIENCE REQUIREMENTS

2 years clinical Medical Assistant experience required.

Experience in data collection preferred.

EDUCATIONAL REQUIREMENTS

Completion of Medical Assistant program preferred.

SPECIAL SKILL AND KNOWLEDGE REQUIREMENTS

Knowledge and ability to manage multiple patients of cultural diversity and low literacy issues in care provisions. Demonstrates outstanding communication skills and can establish constructive relationships with patients, families, and hospital associates.

HIPAA REQUIREMENTS:

Maintains knowledge of and adherence to all applicable HIPAA regulations appropriate to Job Position including but not limited to: Medical records without limitation both paper and electronic, patient demographics, lab and radiology results, patient information related to surgery or appointment schedules, medical records related to quality data, patient financial information, patient 3rd party billing, patient related complaints, information related to patient location, public health records, and/or patients religious beliefs.

SAFETY REQUIREMENTS:

Maintains knowledge of and adherence to all applicable safety practices appropriate to Job Position including but not limited to: Incident reporting, handling of wasters, sharps and linen, PPE, exposure control plans, hand washing, patient identification, receives orders for patients, and monitoring clinical alarms.