BASIC FUNCTION

Serves as a member of the interdisciplinary population health care team Works collaboratively with staff to proactively meet patient care needs, engage patients into health care services, address barriers to access, and facilitate connection to needed services and resources. Plays a critical role in population health care management to enhance quality, reduce cost and improve health outcomes across all patient populations.

PRIMARY RESPONSIBILITIES AND DUTIES 1

)

Population Health Coordination:

Collaborate with healthcare providers, administrators, and other members of care team to deliver population health programs and interventions. a) Manage a panel of patients, working collaboratively with health center staff to engage patients into care, close gaps in care, manage referrals, coordinate preventative care, and schedule recommended appointments. b) Prioritize patients for program outreach utilizing available information, such reports from health plans, risk stratification, software system and data review, referrals from hospitals and providers and patient self-referral, reports, or other data. c) Assign patients to appropriate care managers based on available information. d) Provide timely feedback to referral sources. e) Review patient lists for needed care. f) Assist with pre-visit information documentation and patient outreach for lab, test, and appointment reminders. Ensure barriers to appointment attendance are identified and mitigated. g) Facilitate/assist with daily team huddles, as appropriate. h) Coordinate education, brief intervention and/or facilitation of referrals to and from providers, practice staff, and community-based organizations and other programs/ services in accordance with applicable protocols. i) Coordinate ancillary assistance for patients to assess and address psycho-social barriers that limit engagement in care including advocacy, support and assistance with transportation, health insurance, scheduling, and keeping appointments, and interpreter assistance, as necessary. j) Perform basic administrative duties with high degree of accuracy including note taking, managing team schedules, ordering supplies, arranging office set up, patient registration, reminder phone calls, writing letters, formulating emails, scheduling appointments and meetings for patients and team members, record keeping; and maintaining all forms, databases, protocols, and manuals. k) Track patient data, stratify patient registries, and facilitate provider follow up and referrals to community-based organizations. Generate reports as requested. l) Handle confidential information in accordance with HIPAA as well as other related federal and state confidentiality rules. m) Identify patients at high risk of adverse health outcomes through case finding activities including risk stratification list, provider referrals, or encounter data review identifying high cost/high risk disease states or patients. n) Engage patients in trusting relationships enabling effective intervention and support. Ensure patient understands program benefits, care manager's role, how to make best use of the program, and obtain consent to participate. o) Apply motivational interviewing to conduct assessment(s) of patient condition, needs, preferences, clinical and psychosocial/SDOH barriers to optimal health and identify care/case management intervention opportunities. p) Support the patient in identification of actionable goals to optimize health outcomes. q) Assist with data entry and management for closing gaps of care. r) Work with Excel spreadsheets to provide concise, meaningful data back to the team. s) Attend team meetings, trainings, learning events, and other functions, as required. t) Participate in measurement of care/case management program effectiveness. u) Certified medical personnel (RMA/CMA, etc.) must function under the direct supervision of a physician, Registered Nurse, or Advanced Practice Provider. This role is a supportive one and does not involve making independent decisions regarding infection control practices. 2) Performs other duties as assigned. Effectively carries out tasks and responsibilities beyond core job duties and primary role. The additional duties may vary from time to time and encompass a wide range of activities that contribute to the overall success of the organization (floating, schedule variations, assisting co-workers, patients, visitors, customers, leaders, and other stakeholders in support of the organization.)

MISSION, VISION, AND VALUES 1

) Empathy

Demonstrates a high level of empathy, respect, and understanding of diversity in the workplace by treating all patients, guests and colleagues with dignity, courtesy, and inclusivity, and by actively seeking to learn from different perspectives and experiences. 2) Excellence
Consistently upholds high ethical and safety standards and demonstrates unwavering integrity in all work-related activities. 3) Enjoyment
Displays enjoyment (gratitude), a commitment to learning, and professionalism by actively seeking feedback, accepting constructive criticism, and demonstrating a willingness to grow and improve in their job role. 4) Commitment to Patient/Customer Service
Exhibits exceptional patient/customer service skills, consistently providing professional support.

Demonstrates effective communication skills, actively listening to patients/customers, and responding promptly to inquiries and concerns. Handles challenging situations with tact and diplomacy, ensuring timely resolution of problems and fostering positive patient/customer experiences

CULTURE 1

) Gratitude

Displays a positive and appreciative mindset and supports happiness and well-being in self and others. 2) Collaborative Team
Demonstrates flexibility, enthusiasm, and willingness to cooperate while working with others in an inter-professional team to support organizational activities. 3) Quality Improvement
Collaborates with team to drive continuous improvement initiatives to enhance quality standards, processes, and outcomes. 4) Accountability
Ensures consistent adherence to regulatory guidelines and HealthPoint policies and procedures.

Takes accountability for mistakes and errors.

QUALIFICATIONS

GENERAL

PROFESSIONAL DEVELOPMENT

This position requires a high level of professionalism, strong communication and interpersonal skills, and the ability to handle sensitive and confidential information with discretion. 1) Organizational Skills

Displays more advanced organizational skills, to organize projects or the work of others. 2) Problem Solving Skills
Devises effective solutions to situations encountered which include general goals and objectives. 3) Communication Skills
Able to effectively communicate opinions drawn from conclusions using inference and logic. 4) Critical Thinking Skills
Uses logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems. 5) Problem Resolution
Resolves conflicts that may arise because of disagreements between employees, between employees and customers/clients.

PROFESSIONAL/TECHNICAL KNOWLEDGE, SKILLS & ABILITIES 1

) Processes work-relates skills at a higher level than completion of high school, including formal written and verbal communication skills computational and computer skills mathematical technical or health care related knowledge frequently acquired through a trade school, paraprofessional, or certificate type program. 2) Possess specific knowledge of healthcare processes and practices typically acquired during completion of a certified medical assistant program or health related care program.

LICENSES & CERTIFICATIONS 1

)

Required:

Certification or licensure in health care related field (i.e.:

CMA/RMA, LVN

) or compensatory experience with procession of a high school diploma or General Educational Development (GED). 2)

Required:

6 months of medical assistant related experience 3)

Required:

Completion of updated

BLS/CPR 4

)

Required:

Valid state Driver's License or with reliable transportation.

TECHNICAL SKILLS 1

) Electronic Medical Record Skills

Demonstrates necessary proficiency with all electronic clinical systems, including EHR and scheduling systems, in use at the health center.

2) Familiarity with medical terminology, procedures, and pharmacology, including medication administration procedures 3) Proficient with general medical machines and equipment: Patient Scales, stethoscope, glucometers, PFT testing, Nebulizer treatment administration, medication administration, lab, EKG 4) Proficient with typical office equipment: Copier, telephone, Fax

COMMUNICATIONS SKILLS 1

) Possesses a level of written and verbal communications, including formal written and verbal communication skills frequently acquired through a trade school, paraprofessional, or certificate type program.

PHYSICAL DEMANDS

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