ROLE: Promote Improved health outcomes and Improved patient satisfaction for patients managing chronic conditions within the clinic and community at the direction of the Director of Primary Care Integration. JOB DUTIES: - Work directly with Chronic Condition Care Managers for patients with chronic conditions.
- Process and manage internal referrals to the Chronic Condition Care Managers, the DSME (Diabetes Self-Management Education) program, and other referrals determined by the Chronic Condition Program Manager.
- Provide outreach to patients with diabetes, hypertension, chronic kidney disease, and other chronic conditions under the direction of the Chronic Condition Care Managers, Medical Director, and the Director of Operations and Integration to assist in closing care gaps.
- Complete SDOH (Social Determinants of Health) screening tool for patients who get referred to the various programs overseen by the Chronic Condition Program Manager. Help allocate and provide resources associated to the social determinant needs of the patient.
- Connect patients to the Oral Health clinic, Vision clinic, Patient Advocates, or Behavioral Health Consultant / Behavior Health clinic as necessary.
- Actively recruit patients and assist in programs such as cooking and nutrition classes. Expected to attend and participate in programming, including outside typical working hours to meet the needs of the patients.
- Purchase and coordinate supplies for cooking classes and events.
- Maintain tracking logs for Chronic Condition Programs as determined by the Chronic Condition Program Manager, including any type of grant reporting.
- Track and manage inventory of home blood pressure monitors, blood sugar meters, and continuous glucose monitors
- Assemble education packets for the Hypertension and Diabetes programs.
- Create, print, and distribute flyers for chronic condition programming in collaboration with the chronic condition care team under the direction of the Chronic Condition Program Manager.
- Call patients daily to schedule appointments with the chronic condition care team members and other medical provider appointments. Minimum patient outreach is 30 patients per day.
- Manage all chronic condition referrals for DSME, and help schedule appointments as needed
- Respond to EPIC bubble messages, phone calls, and emails daily from patients and staff.
- Prepare and provide quantitative data for chronic condition grant reporting on time.
- Support the Chronic Condition Program Manager in staff communication and education around new clinical policies and procedures in collaboration with Chronic Condition Care Manager.
- Attend and participate in committees including but not limited to quality, chronic conditions, and advisory groups.
- Attend and participate in the Health Care Home (HCH) Peer to Peer Learning and keep up to date on HCH program requirements in collaboration with the Director of Operations and Integration.
- Attend and actively participate in staff and grant program meetings.
- Collaborate, attend and participate in presentations at in-person and virtual conferences as directed by Chronic Condition Program Manager.
- Assist with other duties and responsibilities as assigned.
KNOWLEDGE, SKILLS, AND ABILITIES: - Commitment to the SCHS mission and staff values.
- Knowledge of the health care environment, specifically Federally Qualified Health Center.
- Has continuous improvement and growth philosophy.
- Attention to detail.
- Ability to maintain essential records and files and prepare clear and accurate reports containing findings, conclusions, and recommendations.
- Self-directed and can interact professionally across multiple disciplines.
- Excellent time management and organizational skills.
- Confidence, professional judgment, and calm under pressure.
- Works well both independently and as part of a team.
- Exceptional communication and interpersonal skills.
- Be flexible and nimble in response to an evolving workload.
- Ability to exhibit good rapport with clients of varying professional and ethnic backgrounds and socio-economic status.
MINIMUM QUALIFICATIONS: - Minimum of two years' experience in a healthcare setting.
- Minimum of two years' experience direct customer service.
- Strong office and administrative skills to include MS Office and other statistical programs.
- Have reliable transportation, valid driver's license, and car insurance.
- Flexibility to work nights, if needed, during reporting season and for special patient centered events and programming
- Fluency (written and verbal) in English and Spanish preferred.
WORK ENVIRONMENT AND PHYSICAL DEMANDS: This position operates in a professional medical clinic/office environment. The role routinely uses standard office equipment. Physical demands include: - Maintain a stationary position for extended periods while performing essential job duties.
- Must be able to operate typical office equipment such as computers, fax machines, copiers, and telephones, as well as instruments commonly found in a medica clinic (e.g., diagnostic tools, medical devices).
- Requires effective verbal and written communication skills to interact with team members, clients, or patients and to complete necessary documentation.
- Discern test results, x-ray results and distinguish physical cues on patients, such as changes in appearance or condition.
- Must be able to recognize and respond to potential signs of health issues or alcohol impairment through appropriate sensory or observational means.
- Occasional movement throughout the clinic, including moving between different areas to perform essential duties.
- Rarely position oneself to retrieve items or perform certain tasks such as connecting or plugging in equipment.
- Occasionally ascend/descend stairs, ladders to retrieve items.
- May need to move items needed for demonstrations weighing up to 20 lbs short distances.
- This position may require regular interaction with individuals who have communicable illnesses, which may pose a risk of exposure to infectious diseases.
Reasonable accommodation can be made for qualified individuals with disabilities to enable them to perform the essential functions of the role.
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