Primary Functions:
· Responsible for patient outreach, assessment, disease management, and care coordination to patients with high rates of medical and behavioral health utilization and/or psychosocial vulnerability · Assess patients through telephonic and eventually face to face encounters · Builds a collaborative relationship with patients and their identified support system to encourage care participation and improve self-management of needs · Utilize motivational interviewing to identify barriers and facilitate care plan compliance · Effectively educate patients about healthcare delivery, plan benefits and a variety of topics related to health, and community resources · Coordinates timely and appropriate implementation of assessments, care plans, and interventions for the identified patient population · Provide medication reconciliation and support ongoing adherence · Provide transitional care management · Identify and helps to align patient care and community resources to prevent hospital readmissions and Emergency Department visits · Document all activity in the documentation systems relevant to the role · Collaborate with the care team to achieve high-quality, low-cost outcomes for patients. · Interface and maintain positive relationships with key providers in the local hospitals, community practices, and organizations to ensure proper patient engagement and follow up · Achieve established productivity targets · Maintain compliance with the organization policies and procedures · Demonstrate the ability to adapt, innovate and lead in a fast-paced environment, where change is common · Passionate about making a difference in individual’s lives · Other duties as assigned |
Qualifications:
Additional skills required:
Benefits:
| Location | Jacksonville, North Carolina |