Strength Through Diversity
Ground breaking science. Advancing medicine. Healing made personal.
- Interacts with patient and family caregivers as appropriate to ensure continuity of care, patient adherence to care plan, and identification of barriers preventing adherence to care plan/intervention.
- Collaborates with patient’s care team to compile information regarding patient’s needs and reviews documentation to assist in developing and implementing a comprehensive care plan/intervention.
- Coaches patients and family caregivers on how to use existing skills and develop new ones to make lifestyle behavior changes that can positively affect patient’s health using different behavioral change modalities. Provides health education related to symptom management and preventive care at an appropriate health literacy level and in patient’s preferred language in collaboration with care team.
- Identifies and addresses system issues that impact barriers to patient’s care. Explores and explains all options available to address the patient’s needs. Encourages self-advocacy by educating patient and family caregiver on how to effectively navigate the healthcare system. Confirms patient and family caregiver’s understanding of needs and options.
- Coordinates care with other members of the care team to overcome any identified financial, legal or social barriers that inhibit patients’ medical care. Refers patients to health system and community resources to ensure patients have appropriate resources to overcome barriers to care (e.g. transportation, home care, durable medical equipment, pharmacy, housing, legal). Researches additional resources to expand knowledge base and make appropriate referrals.
- Monitors the patients' goals and improvements in health outcomes with the care team. Focuses on preventive care and aims to reduce unnecessary medical utilization and as result improves quality of care. Assists care team to close care gaps for individual patients on their panel, communicating these gaps with care team, and collaborating on a plan. Reviews standardized reports (e.g. quality, utilization, and productivity) and takes action as appropriate.
- Documents all patient encounters in relevant documentation system in accurate and timely manner.
- Participates actively in all program and practice staff meetings, case conferences and work groups, and professional development workgroup sessions.
- Bachelor’s degree required, preferably in a health related profession
- None required, some experience in healthcare or related field preferred.
- Bi-lingual (English/Spanish) highly desirable.
- Ability to learn hospital ambulatory scheduling system, electronic medical record and new applications used for care coordination.
- Must have excellent oral and written communication skills and ability to foster a supportive environment for patients.