- Functions as a liaison for patient / caregiver / family in navigating the continuum of care and serves as a patient advocate in inter-disciplinary meetings.
- Collaborates with the patient-centered medical home inter-disciplinary team including providers, pharmacists, dentists, behavioral health providers, chronic disease specialists, community health workers, and nurse / nursing support personnel to achieve patient outcomes.
- Interacts with patients, caregivers, provider teams and the community to achieve continuity of care, coordination of services, timely follow-up, and care planning.
- Identifies early risk factors, conducts ongoing health assessments, and develops and maintains accurate care records of each referred patient within the electronic health record.
- Collaborate with health plans, hospitals, and utilize internal reporting capabilities to identify patients who have a recent hospitalization or emergency department visit.
Distributes patient follow-up to the Chronic Disease Specialists for outreach and appointment scheduling.
- Proactively identifies and addresses barriers to care. Maintain a current list of community agencies and resources to provide to patients, caregivers, and provider teams.
- Provides support services and / or appropriate referrals for patient, caregiver and family as recommended by the inter-disciplinary teams.
- Assures quality of care by adhering to evidenced-based guidelines; measures health outcomes against patient care goals;
makes recommendations to the care team when necessary.
- Participates in the Quality Program through incident reporting and identifying opportunities for
- Participate in the Compliance Program through fraud, waste, and abuse prevention, detection, and reporting; and protecting patient confidentiality under HIPAA.
- Participate in the Infection Control Program through following hand washing and Bloodborne Pathogen safety and exposure protocols.
- Other duties as
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