OVERVIEW OF THE POSITION:
Responsible for a panel of patients and, in collaboration with other members of an integrated primary care team, helps patients meet their preventive, chronic and acute care needs by being mobile and interacting with them where they are, in their communities and homes. Engages patients and encourage them to take an active role in their health by providing them with the tools necessary to make healthy lifestyle choices and adopt lifelong healthy behaviors. Gleans information from conversations with patients and helps develop, implement and manage holistic care plan with care team. Fosters trusting, supportive, collaborative and lasting relationships with patients and their families in a clinical setting, working alongside medical providers in a collaborative, empathetic team by maintaining rapport and open lines of communications with patient to ensure their needs are met and continuity of care is maintained. Serves as primary point of contact with care team and helps coordinate care, navigate the healthcare industry, and troubleshoot in a crisis or to be a listening ear. Works alongside and will be supported by a care team associated with each patient.
Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
Serves as the primary point of contact for the patient by providing administrative guidance throughout the entire healthcare process and functioning as the individual who assists the patient in navigating all aspects of the healthcare industry including government regulations.
Engages in patient advocacy, empowers patients to take charge or leadership in their healthcare and coaches patients to ask questions to understand their disease process as well as treatment plan.
Assists in patient care coordination that is purposeful and supportive and steers a care team, constantly communicating with other team members around patient needs and desires.
Follows a panel of patients to coordinate all aspects of their care.
Meets with members in their homes, neighborhoods and throughout the complicated paths of the healthcare system.
Communicates with every patient on your panel at least twice a month.
Conducts regular friendly outreach calls to patient to track continuity of care and anticipate concerns or questions.
Coordinates care for patients by identifying and addressing their barriers to and social influences on good health.
Captures relevant information about the patient’s health and healthcare experience and performs standard age and condition-appropriate screening assessments.
Helps execute on treatment plan developed by the clinician, which includes arrangements for referral to services as appropriate.
Learns about the chronic health conditions that span the patient panel and helps patients take preventative care measures as instructed by their clinician.
Facilitates communication with patient and caregiver and coordinates patient care with appropriate resource allocations, referrals and notifications that are purposeful, supportive and interconnected with care team to ensure ongoing coordinated management of patient care.
Provides anticipatory preventive guidance to families with children and establishes healing relationships with members and families.
Provides community resource information and performs referral and liaison activities as necessary for the patient’s ambulatory care.
Maintains current information on all frequently used community resources, financial resources and placement facilities.
Supports care team through collection of information available in EHR, PIR, from the patient or caregiver to remind and alert team of any concerns, change of condition in patient or recent ED / UCC / hospitalizations.
Initiates sincere special occasion touch base functions, such as birthday and holiday greetings, phone calls and cards.
Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Performs additional duties as assigned.
1 to 2 years of post-high school education or a degree from a two-year college.
Bachelor’s degree preferred.
Over 2 years of experience in customer service / sales capacity.
Experience with managing complex schedules and managing relationships.
Over 1 year and up to and including 3 years of experience in a healthcare setting.
Prior experience in a health plan, medical group or IPA setting working with physician networks.
Experience in utilizing a clinical information systems.
Previous supervisory experience.
KNOWLEDGE, SKILLS, ABILITIES:
Proficient in Microsoft office applications (Word, Excel).
Ability to interface effectively with patients, providers, management and employees of the organization as well as facilities and agencies in the community.
Ability to effectively use organization’s health information technology resources in patient management.
Health literacy and cultural awareness skills.
Good critical thinking skills and resourcefulness.
Effective organizational, multi-tasking and follow-up skills.
Ability to problem-solve to effectively assist patient with issues and challenges.
Excellent verbal and written communication skills with ability to read, write, speak and understand English clearly.
Ability to transfer knowledge to patients with diverse cultural backgrounds while effectively coordinating their care.
Ability to build lasting rapport with patients from a wide variety of cultural and socio-economic backgrounds.
Ability to exercise objectivity and good judgment relating to difficult and emotionally charged situations.
Bilingual skills (based upon demographic needs of panel).
Valid California driver’s license, insurance and vehicle for work-related travel.