Provides support for the Vital Signs Wellness Chronic Care Management program by coordinating a comprehensive plan of care. Facilitates the transmission of information between providers and patients as well as access to services needed. Provides advocacy, information and referral services to patients and families to address their medical and psychosocial needs.
DUTIES AND RESPONSIBILITIES
Communicate effectively with doctors and other healthcare professionals the status of clients and their current needs. Review client's medical preferences, pharmacy, providers and clinicians and make referrals based on need. Advocate for and provide information to patients and their families based on necessity. Establish a relationship of trust and support that continues over time as needs of patients change. Learn to effectively utilize the portal and all software systems needed. Represent Vital Signs Wellness in a caring and professional manner to doctors and other health professionals. Complies with Compliance plan and HIPPA Policies. Maintains confidentiality of information relating to the patient and family with those directly involved in the patient's care. As business needs may change, may perform additional responsibilities assigned by the supervisors that are reasonably related to the position. Follow coordination of care Medicare guidelines on chronic care management. Develop rapport with patient, gain trust and obtain consent. Completion of coordination of care minimum of 20 minutes per patient per month. If unable to complete coordination of care must specify the reason why coordination was not attained. If no CPT code formulated, it is not a reimbursable code/time. Coordinate with all care-team members involved with care: patient, caregiver, pharmacy, hospital, consult team, home health, hospice, nursing home, etc. Introduction of advance care planning - do not resuscitate orders, etc. Completion of screening schedule yearly for each patient: annual wellness screen and transitional care management. Utilization of chronic care codes on chronic care diagnosis only. Utilization of Behavioral Health codes for all Behavioral diagnosis codes only. Utilization of Remote Physiologic Monitoring (RPM) for physiologic data i.e. blood pressure, pulse, weight, and glucose levels.
MINIMUM JOB REQUIREMENTS
Experience:
Experience in customer service. Experience with dealing with a patient in a clinical setting.
KNOWLEDGE, SKILLS, & ABILITIES
Ability to plan and organize time effectively, work independently and show good judgement. Must have excellent problem-solving and critical thinking skills. Ability to deal effectively and courteously with clients, family, physicians, medical professionals and co-workers. Ability to interact and exhibit an empathetic attitude toward the sick and elderly. Must maintain confidentiality of client records and information. Must be proficient with computer use, keyboarding skills, Microsoft Office, and Google docs. Ability to work independently and with initiative to meet work production expectations. Ability to communicate effectively, verbally and in writing. Friendly, caring, attentive and listening voice. Ability to work on-call as needed
PHYSICAL DEMANDS AND WORK ENVIRONMENT
Constant sitting, constant reach with arms and hands Constant keyboarding and fine manipulation Constant close vision and manual dexterity Occasional reaching above shoulder level This role offers a unique opportunity to make a meaningful difference in the lives of patients by delivering high-quality wound care in the comfort of their homes. If you are passionate about improving patient outcomes and are dedicated to providing compassionate, personalized care, we encourage you to apply.
