Primary Function/General Purpose of Position
Promote the health and welfare of assigned patients as a member of Interdisciplinary Team (IDT) caring for the patient, ensuring the patient’s individual needs are identified and addressed in a timely manner. Act as patient advocate to address primary physical and social needs including assessing and linking community resources available to the patient, as well as ensuring patients assigned have timely access to services they need while respecting the rights and wishes of the patient and family. Provide care coordination services for eligible patients, supporting the ambulatory care management team to address barriers, facilitate access to clinical services, reinforce education of self-care activities and healthy behaviors, and align to appropriate community resources.
*This is a remote/work at home position. Hire must be open to working eastern time zone hours.
Essential Job Functions
Maintain a caseload of patients according to department policies.
Identify, enroll and/or refer patients to Ambulatory Care Manager for Transitions of Care/Complex Case Management/Chronic Disease Management as appropriate based on department protocols.
Support execution of developed care plans to maximize healthcare outcomes and facilitate wellness with periodic review and update according to department protocols.
Perform medication review and teach-back to ensure patient understanding and ability to adhere to medical regimen.
Contact patients, caregivers and families to ensure preventive services are received by assigned patients.
Perform patient outreach according to established protocols and document in electronic medical record.
Educate patients on availability of resources for primary care and acute care along with alternative community programs and services that promote sound health, lifestyle and well-being.
Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, and right time.
Assist patient in advanced care planning to complete Advanced Directives as appropriate.
Obtain and coordinate access with primary care providers and other specialty providers including behavioral health ensuring necessary records and documentation of referrals are completed and reconciled.
Identify, execute, and track needed referrals to care and community resources.
Document all communications with patient and/or care team in electronic medical record.
This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation.
Licensing/Certification
Licensed Practical or Vocational Nurse with active License in State of Patient Care (required)
Community Health Worker certification or working toward certification, Certified Health Coach (preferred)
Education
Required Minimum Education- High School Diploma
Specialty/Major- Licensed Practical Nursing
Work Experience
2 years experience in community based setting, home health or case management experience
Other Knowledge, Skills and Abilities Required
Excellent interpersonal communication and negotiation skills. Strong analytical, data management and computer skills.
Demonstrate basic knowledge of healthcare and health education across the lifespan in a practice health setting.
Ability to work with individuals, groups and families. Familiarity and knowledge of Community Resources. Flexibility to work non- traditional hours. Works well in a Team Setting.
Personal computer skills.
Experience with database entry, EMR documentation, Power Point preferred and basic Excel skills.
Highly organized and detail oriented.
Accepts responsibility and follows through on projects and activities
Other Knowledge, Skills and Abilities Preferred
Demonstrated success in improving the health of a distinct population of patients in the ambulatory or community setting.
Experience in a healthcare related environment working with patients, families, and providers.
Preferred knowledge of managed care requirements both public and private
Many of our opportunities reward* your hard work with:Comprehensive, affordable medical, dental and vision plans
Prescription drug coverage
Flexible spending accounts
Life insurance w/AD&D
Employer contributions to retirement savings plan when eligible
Paid time off
Educational Assistance
And much more
*Benefits offerings vary according to employment status
All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employers, please email recruitment@mercy.com. If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com