Position Summary Committed to the constant pursuit of excellence in improving the health status of the patient and decreasing Emergency Room visits/readmission rates, ensures the safe and effective transfers of patients across the care continuum, serving as the bridge between the professional staff in a care setting (e.g. Clinic), the patient and/or family, and the community healthcare provider. Informs and guides both staff and patients working to ensure an effective care transition from the Clinic to the patient’s home; helps teach and train patient self-management skills as well as enhancing patient-healthcare provider communication; and provides support to Hospital personnel and community partners in the field and provides assistance by phone or in-person to high-risk beneficiaries by identifying social determinants of health and connecting them to community services. This position does not have direct reports. Essential Functions:% of Time EnrollmentAccepts referrals from Dignity Health Internal Medicine Clinic PhysiciansMeet with patient/family in the Clinic to introduce the program and gather enrollment dataReinforces program enrollment and patient responsibilities with the patient and/or caregiverPrioritizes referrals and activities according to acuity, needs, and required follow-up working to ensure outcomes are met20%AdvocacyEnsuring professional boundaries are maintained with all aspects of patient’s interaction and care delivers patient care advocacy to include: Serves as a Patient Care Advocate to the patient, coaching the patient and caregivers in addressing social determinants of health Provides information and navigation to the patient and/or family for an effective care transition, improved patient self-management skills and enhanced patient-healthcare provider communicationEvaluates aspects of each patient’s condition, diagnoses, medications, and support systems to formulate an individualized plan which will lead to successful outcomes in:Medication self-managementUse of a dynamic patient-centered recordAppropriate primary care and specialist follow-upKnowledge of red flagsReinforces instruction from medical providers and interdisciplinary team, does not provide clinical or medical adviceServes as a liaison between primary care providers, and community resources on behalf of patients to ensure patient-centered coordination of careWorks in the Clinic and community, makes home visits and follow-up phone callsActs as a continuing resource for the Clinic personnel, patients and/or caregivers 45%Data Collection & Custodian of RecordsCompletes the necessary assessments and referrals by collecting data on clinical indicators Maintains databases on CATCH-enrolled population ensuring accurate and timely documentation20%Continuous Improvement & QualityEnsures compliance with all FSL policies, procedures, and practices regarding the CATCH Transitional Care program, and other contract and licensure requirements laws related to patient confidentiality, release of information, and HIPAA; and applies knowledge to the work in accordance with quality standardsUses safe work practicesPromptly reports workplace and patient safety issues to supervisorAttends and actively participates in initial and on-going training and development programs and opportunities, weekly unit meetings all staff meetings, and demonstrates learned concepts on the jobParticipates in assigned work teams, as requested and appropriateEngages in continuous improvement efforts, as assigned, and strives to continuously improve the quality of care and selfCommunicates daily and as necessary with colleagues, supervisor, leadership and medical staff10%MiscellaneousBuilding, cleaning, and organizing durable medical equipment Other duties as assigned 5% RequirementsEducation & Experience, Knowledge/UnderstandingBachelor’s Degree in Social Work, Human Services, Psychology or Public Health or Nurse (LPN or RN) Licensed by the Arizona Board of NursingMinimum of 2 years of working with patients in a primary care setting or related work experienceValid AZ driver’s license and acceptable MVRValid CPR/First Aid Certification or ability to obtain within 30 days of position entryMust be at least 21 years of ageClear fingerprint background screening through the Department of Public Safety and comprehensive background clearance SkillsExcellent verbal, written, reading, and listening communication skills to include communicating clearly, effectively, tactfully, and patiently to a diverse populationStrong interpersonal skills and demeanor with the ability to build rapport and garner trust with othersAccurate keyboarding skillsStrong planning, organization and time management skills in order to meet deadlinesProficient in the use of healthcare data management systems such as CarePort, Cerner, and ApricotProficient in the use of a PC; in a Windows environment; in the use of the Internet; and in the use of MS Office Applications such as Outlook, Teams, and Word, and the use of SharePoint AbilitiesAbility to interact with others in a professional, respectful, positive, helpful manner, promoting trust with others, and build and maintain strong, effective working relationships with internal and external customersAbility to follow-up and follow-through with strong attention to detailAbility to follow oral and written instructionsAbility to maintain patient confidentiality, privacy and dignity at all timesAbility to work both independently and collaborative as part of a teamAbility to travel up to 50% of the time within the Greater Metropolitan Phoenix area using personal vehicle properly insuredAbility to solve problems by applying analytical skills to include:collecting and reporting informationIdentifying trends and exceptionsinvestigating to define problems more accuratelysorting information in order of importanceidentifying relationships and linkages between componentsidentifying variable potential causes and effectssoliciting guidance to define criteria and assign values of importance and urgencyescalating issues of an exceptional natureWillingness and ability to embody FSL’s core values:Have passion for our mission Follow the golden ruleDo the right thing Begin with a can-do attitudeFind a better wayBe your best Physical DemandsThe physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position.The work environment characteristics described are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.Normal office environment; clinical or patient care setting to include hospitals, physician offices, clinics and patient homes.While performing the duties of this position, the employee is regularly required to: talk and hear, including over the telephone, in normal range; use hands to finger, handle or feel objects, tools/equipment or controls; sit for extended periods of time, stand, reach with hands and arms, and walk. Occasionally required to stoop, kneel or crouch; lift and/or move up to 30 pounds. Vision required includes close vision, distance vision, and ability to adjust focus PreferencesHealthcare experienceKnowledge of needs of older adults, the aging process, and the needs of adults with Disabilities, adults with traumatic brain injuries (or TBI) or SMIBilingual in English/Spanish