Job Description

Essential Responsibilities

  • Maintains Chronic disease registry and enter, tracks and updates patient information.
  • Makes appointments and sends reminders of regular and ancillary visits and preventive care.
  • Reviews registry for overdue lab work.
  • Using registry to target patients for chronic disease care management activities such as making sure patients come in for regular visits, preventive care actions that are overdue, and other triggers for panel manager attention.
  • Develops and implements a mechanism for tracking referrals and ensuring clients successfully follow-up on referrals according to timing protocols that are implemented.
  • Assist with eligibility determination to ensure access to services.
  • Conducts “messenger” activities (eg. delivers brief message about refills or appointment scheduling, remind patients to bring medication bottles to all visits.
  • Maintains regular communication with other clinical staff involved in panel management.

Patient Support

  • Discuss prevention techniques and maintenance of self-management goals with patient of key care standards such as regular eye exams or HgbA1c tests.
  • Encourage Clients access to integrated health care. Assist patient to access a range of services that may be outside clinic, e.g. ancillary, specialty, referrals, social networking referrals.
  • Using motivation interviewing techniques, coach patients in self- management, e.g. medication reconciliation and lifestyle, glucose self-monitoring skills and exercise in person and over the phone.
  • Leads patient groups that integrate psychological, clinical, exercise and dietary principles.
  • Teach staff and employees about the pathophysiology of chronic diseases.
  • Meet with patients’ provider for case review and additional patient needs.
  • Address questions concerning medicines. Test results or instructions that they receive from Primary Care Providers.
  • Continuously improve patient health coaching techniques using evidence-based PDSA (Plan, Do, Study, Act) approaches.
  • Together with Wellness Team, set goals for the achievement and exceedance of HEDIS and CHCN goals. Develop and implement plans to improve those goals.
  • Compile reports of patient health outcomes, and progress with achieving health metrics.
  • Monitors and evaluates short and long-term patient responses to interventions; tracks and maintains necessary follow-up for patients.
  • Reviews patient medications and assists with refill requests.

Other Responsibilities

  • Participate actively and constructively in performance improvement activities regarding chronic illness care issues.
  • Outreaches to new patients in need of chronic disease management, e.g. at churches, schools, health fairs, Senior center etc.
  • Provides services including blood draws, BP, and Blood sugar checks at the Fremont Senior. Center.
  • Work at Fremont Senior Center according to contract requirements.
  • Attend workshops, training and meetings as needed, and as requested.
  • Perform other duties as assigned by Manager.
  • Observes, recognizes, identifies and interprets serious and /or emergent situations and initiates appropriate interventions.
  • Follows standards of care and TCHC’s chronic care policies and procedures regarding disease management, case management and care coordination.
  • Monitors and evaluates patient data and works with the Provider to determine level of care to maximize positive clinical outcomes.
  • Acts as liaison between patient and provider to communicate patient needs and concerns as necessary.
  • Intervenes to positively effect healthcare outcomes with emphasis on patient’s self-management of their disease.
  • Maintains compliance with state and federal regulations and guidelines, in day-to-day activities.
  • Participates in TCHC’s Continuous Quality Improvement program.
  • Works flexible schedule and overtime, as necessary.

Required education, experience, and training

  • High School Diploma
  • Completion of LVN program
  • Active phlebotomy certificate/blood draw certification.
  • 1-2 year work related experience in medical environment.

Application Instructions

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