Benefits:
401(k)
Flexible schedule
Health insurance
Paid time off
Wellness resources
SOMOS Innovation, LLC is the organization that has been built to deliver on a simple promise – to provide the administrative infrastructure to enable our physicians to deliver high-quality community healthcare to our vulnerable Medicaid and Medicare patients in a culturally appropriate manner. The physician leaders of Corinthian Medical, Excelsior Medical, Balance Medical, SOMOS Your Health, SOMOS, and Eastern Chinese IPA have seen that to succeed in a VBP world the IPAs and physicians must be supported by an integrated management services organization. The MSO must deliver a portfolio of managed care contracts and the infrastructure to manage the financial risk attached to those contracts. The MSO must deliver administrative simplification for the PCPs and IPAs that generates more patient time and enables the PCPs to deliver the right care, at the right time in the right setting. The MSO must deliver clinical innovation that moves “population health” from theory to practice. The following grid highlights the functionality delivered to each of the IPAs.
Patient Assessment and Coordination
Conduct initial and follow-up assessments focused on patients’ medical, psychological, and social support needs under the direction of the RN Care Manager.
Assist in developing and implementing individualized care plans in collaboration with the RN Care Manager and interdisciplinary team.
Monitor patient status through telephonic and in-person outreach to ensure continuity of care.
Support Care Management face-to-face assessments in the home, community, or clinical setting as directed by the care team.
Patient and Family Education
Provide patient-centered education on care plans, medications, chronic disease management, and preventive health practices.
Support families in understanding available health plan resources and empower them to make informed decisions about care.
Reinforce patient self-management goals identified by the care team.
Care Transition Management
Assist in care transition activities by coordinating follow-up appointments, medication reconciliation support, and patient/family education after discharge.
Communicate patient status and needs effectively to providers, RN Care Managers, and other team members to support safe transitions between settings (e.g., hospital, rehab, home).
Resource Coordination
Identify patients in need of social services or community-based resources and route referrals to the appropriate non-clinical coordinators or social workers.
Act as a liaison between patients, caregivers, and the healthcare team to promote access to needed medical and social supports.
Provide ongoing support to clinical staff by tracking progress toward care plan goals and reporting barriers or successes.
Documentation and Reporting
Maintain timely, accurate, and comprehensive documentation in the electronic health record (EHR) in accordance with organizational standards and regulatory requirements.
Prepare and maintain tracking logs for outreach, education, and follow-up activities.
Contribute to reporting on patient progress, barriers to care, and program outcomes.
Clinical Risk Escalation
Identify potential clinical concerns, deterioration in condition, or risk issues during patient outreach.
Promptly escalate concerns to the RN Care Manager or Supervisor for higher-level intervention.
Collaborate with the interdisciplinary team to address clinical issues and prevent avoidable adverse outcomes.
Other Responsibilities
Participate in mandatory in-person team/company meetings, ongoing training, and case reviews.
Provide updates on assigned patients at interdisciplinary team meetings.
Perform other duties as assigned in support of patient care and program objectives.
Qualifications
Current and valid LPN license in the state of practice.
Strong clinical knowledge of chronic disease management, preventive care, and medication adherence.
Prior experience in care management, managed care, community health, or ambulatory care preferred.
Excellent communication, interpersonal, and organizational skills.
Compassionate, patient-centered approach with the ability to build trusting relationships.
Proficiency in EHR systems and intermediate computer skills (Excel, Outlook, Teams, Word, etc.).
Ability to manage multiple priorities, meet deadlines, and work both independently and as part of a multidisciplinary team.
Skilled in motivational interviewing and patient engagement strategies.
Demonstrated time management and critical thinking skills.
Job Type: Full-time
Pay: From $75,000.00 per year
Benefits:
401(k)
Health insurance
Life insurance
Paid time off
Vision insurance
Language:
Spanish (Required)
License/Certification:
LPN (Required)
Work Location: Hybrid remote in Bronx, NY 10463
Flexible work from home options available.