GENERAL DESCRIPTION OF POSITION:
Provide health promotion and disease prevention education to patients of the Clinic. Serves as a health advocate and provides basic information regarding clinic and community services. Promotes Su Clinica (SC) services and encourage visits and screenings to meet health indicators including, but not limited to, Accountable Care Organization, Uniform Data System, Patient Centered Medical Home (PCMH) and any other clinical measures important to the care of the patient.
As a member of the clinical team, this position requires total support to the PCMH principles, policies, and procedures. Duties will involve clinical and clerical in order to deliver optimal patient care services within the scope of the Care Manager’s expertise. Will perform duties to ensure the patient has a pleasant and satisfactory experience in the manner in which their health care is delivered, managed, coordinated with both internal and external entities, and in which the patient participates in decision making.
This position will require some evenings and some weekends.
ESSENTIAL JOB FUNCTIONS: (with or without accommodations)
Patient relationship: Greets and welcomes the patient in a pleasant, respectful, culturally and linguistically appropriate manner. Assures patient questions are answered in a positive and cordial manner. Assures the patient has a clear understanding of all communications. Reinforces to the patients the importance of keeping appointments or communicating changes in their appointments.
Provides accurate and appropriate health information utilizing health literacy and culturally competent techniques to Clinic patients.
Serves as a bridge between the patient and SC’s services as well as other community health, human, and social service organizations.
Conducts home visits on behalf of the clinic to provide education and SC’s health services upon the request of a physician, nurse, or social worker, or the patient as needed. Communicates patient’s problem/complaint to the provider. Asks the required questions for a proper assessment. Coordinates all delivered information to the appropriate Clinic source.
Management of patients care: Provides education and assist patients with navigation of clinic services to promote recommended health screenings, reduce health disparities, and improve patient care outcomes. Make calls and conducts home visits on behalf of the clinic to provide education and SC’s health services upon the request of a physician, nurse, or social worker, or the patient as needed to encourage appointments, follow up on unique patients, and no shows. Assumes Certified Medical Assistant duties clinic wide as needed for coverage. Arrives patients and schedules for follow-up appointments. Verifies that patients and family members’ questions have been addressed and that appropriate educational materials are provided. Conducts regular follow-up with patients to evaluate progress, promote continuity of care and ensure improved outcomes.
Manages patient information: Adheres to all Health Information Portability and Accountability Act regulations in and outside of the Clinic. Communicates patient information as requested to enhance patient services. Maintains documentation of activities and assist in tracking data related to health promotions encounters. Maintain a productivity log and accurate records of case management activities. Assures that patient information and records are completed in a timely manner. Ensures patients’ treatment requirements are met.
Team communication: Actively participates in team huddles to assure maximum appointments, gaps in the day. Works with unit team members as well as other clinic personnel to ensure a smooth patient flow. Communicates specific patient needs and/or population management information. Conducts individual and or group health education presentations both at the Clinic and at community sites. Attends and participates in all Clinic staff meetings, work groups as directed. Assists in the orientation of new employees or students in the department. Communicates patient’s problem/complaint to the provider. Conduct individual and/or group health education presentations both at SC and at community sites. Ensures all community referrals will be coordinated with the referral clerks and with the social worker
Demonstration of safe and professional conduct: Maintains a friendly environment for self and others. Responds to emergency situations as per training. Refrains from texting and speaking on the cell phone while on duty. Refrains from informal communication with patients and others. Participates in the performance improvement and follows all the Clinic policies and procedures. Attends work on a regular and predictable schedule in accordance with Clinic leave policy and performs other duties as assigned. Submits required documentation in a timely manner (credentialing requirements, license renewals, certifications, continuing nurse education attendance, etc.). Performs other duties as assigned. Must always adhere to a professional appearance in dress and behavior/conduct.
POSITION DIRECTLY SUPERVISED: None
