Benefits:

401(k)

401(k) matching

Dental insurance

Health insurance

Paid time off

Training & development

Vision insurance

Summary of Duties:

· Assists all patients through the healthcare system by acting as a patient advocate and navigator.

· Participates in Patient-Centered Medical Home team meetings and quality improvement initiatives.

· Facilitates health and disease patient education, including leading group office visits.

· Supports patient self-management of disease and behavior modification interventions.

· Coordinates continuity of patient care with external healthcare organizations and facilities, including the process of hospital admission and discharge and referrals from the primary care provider to a specialty care provider.

· Coordinates continuity of patient care with patients and families following hospital admission, discharge, and ER visits.

· Manages high-risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting, including a registry.

· Conducts comprehensive, preventive screenings for patients and/or assists all support staff in daily patient interactions as needed.

· Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.

· Facilitates patient medication management based upon standing orders and protocols.

· Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Patient-Centered Medical Home and Medical Neighborhood initiatives.

· Evaluates the patient’s views on clinical care, utilization of resources, and assists in the development of new clinical tools, forms, and procedures.

Education and Experience:

· Essential:

Ø Graduation from an accredited university with a background in science, including a BA or BS in Biology, Chemistry, Nursing, Anatomy and Physiology, Public Health, Behavioral Science, or a similar degree is preferred not required, however relevant skills in clinical settings working with diverse populations is required

Ø Proficient computer skills, including Microsoft Office (specifically Word and Excel)

Ø 2-5 years experience in a clinical setting

Ø Self-disciplined, energetic, passionate, innovative

Ø A team player that can follow a system and protocol to achieve a common goal

Ø Highly organized and well-developed oral and written communication skills

Ø Demonstrates sound judgment, decision-making and problem-solving skills

Ø Able to maintain confidentiality with all aspects of information in accordance with practice, State and Federal regulations

Ø Confidence to communicate and outreach to other community health care organizations and personnel