Works with CCT Director, CCT Medical Director to establish patient selection criteria/High Risk Registry
In consort with the CCT Medical Director/Director, attending hospitalist, specialist, or primary care physician (PCP), evaluate the patient's care plan, and recommends appropriate, timely, and beneficial interventions which promote quality, appropriate and cost-effective health care outcomes.
Provide follow-up when transitions occur, possibly including performing home visits for applicable patients, and ensure a smooth transition from hospital/community facility to home.
Assures the consistent implementation of the treatment plan through ongoing coordination and communication with various health care team members. Collaboratively functions across the continuum of care providing 24/7 coverage as needed.
Actively participate in a hospital care transition and a no discharge improvement program.
Utilizing health behavior change techniques, identify patient readiness for self-management and barriers to optimal care, and implement interventions that address patient needs with the goal of improving or maintaining the health status of the patient.
Evaluates the outcome of the plan through phone calls, return visits and home visits.
Document care required in electronic health record or registry.
Participate in daily care team huddles, weekly meetings, and initiatives as they relate to improving operations, patient education, gap closure (healthy living programs) and reducing preventable hospital readmissions.
Participates with on-call and weekend coverage rotation with the CCT. Our team provides 24/7 coverage for the hospital and ambulatory clinics.
Attend training and educational seminars as approved by the CCT Director that are geared toward improving patient education on chronic disease self-management and reducing preventable hospital readmissions.
Identify trends and opportunities for improvement in care of patients with chronic diseases and make recommendations for changes in systems and programs, applying "lean" methodology when appropriate.
Actively participate and lead initiatives in any Payer Pay for Performance or Quality Improvement Plan as designated by the Sr Director of Population Health or the CCT Director.
Effectively communicates and engages with core members of healthcare team across the continuum of care.
Critical thinking:
Has ability to prioritize, consider all possibilities and determine most likely solution as relevant to case
Reports all problem cases and situations to supervisor
Displays problem solving skills
Can organize information to promote decision-making
Demonstrates ability to manage caseload
Maintains appropriate community resource files
Demonstrates knowledge of medical terminology and range of treatment needed by the patient
Demonstrates knowledge of growth, development, and age specific interventions
Quality Assurance Oversight:
Supports IDL and CCT team in developing appropriate integrative Care Pathways, Protocols, Quality Metrics, Tracking and Auditing tools
Supports the development of care pathways, standards, and development of a narrow network of skilled facilities
Leads new initiatives to support patient care across the continuum in a no discharge process that includes care gap completion
Provides clinical interventions/recommendations to team in daily huddles with difficult case presentations
Assists the CCT team in coordinating clinical team to recognize and resolve care gaps
Ensures Consenting process is approved and completed for CCT patients
Ability to work as a part of an inter-disciplinary team with primary care physicians and other clinician’s in a professional manner.
Displays evidence of excellent leadership skills along with verbal, written, and interpersonal skills. Displays critical thinking and clinical problem solving skills
All other duties as required or assigned:
Ability to travel to patient homes and physician offices.
Ability to adapt to evolving goals and requirements and to test new approaches to improved patient care.
Perform other duties as required.
Education / Experience:
Bachelor’s degree in social work, required.
3+ years in Healthcare/Medical, preferred.
Requirements:
Knowledge of social service resources and agencies in the community.
Culturally attuned to the people of the community being served, able to communicate, sensitive and compassionate.
Very knowledgeable of the environment and system through which the patient must move to obtain care.
Ability to prioritize assignments and to organize workload.
Computer skills with proficiency in Electronic Health Record, Microsoft Products (Word, Excel, Outlook, and PowerPoint). Experience with Electronic Medical Records.
Certification & Licensures: - N/A
Seniority level
Entry level
Employment type
Full-time
Job function
Other
Industries
Medical Practices and Hospitals and Health Care
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