Description

Size of Role 

Provides CKD nephrology patients direct access using Phamily software Platform. Works both directly and indirectly with nephrologists, Advanced Practitioners, clinical staff, Patient Navigator, Care Coordinators and ESRD Transition Coordinators in promoting an optimal patient experience beginning at time of intake.

Critical Relationships

Providers, Director of Value Base Care Operations, Clinical Staff, Patient Services Staff, Patient Navigators, ESRD Transition Coordinator, Dialysis Organizations, Hospitals and Referral Sources

Overall Job Purpose

A non-exempt position responsible for working directly with patients and their families to engage patients to help identify unmet needs, gather summary information for treatment interventions, and enhance ongoing communication between the patient and their care team. Works directly with patients and their families to coordinate timely healthcare services following hospitalizations.

• Proactive weekly contact with patients to review current medications, understanding of provider guidelines and compliance to care as outlined by provider. Identifies any new medications taking since last visit, hospitalizations and any new diagnosis identified from other care providers.
• Triage and assessment of patient’s health status
• Coordination of care between patient and provider
• Active review of patient’s charts to assess health needs and gaps.
• Assesses patient’s knowledge of late-stage CKD and treatments, help to educate, and inform patients so that they can make informed decisions regards to the steps to manage health issues during transitions to ESRD
• Communicates upcoming appointments for Nephrology visits, access placement with patients and identifies any barriers to compliance with those appointments
• Communicates any changes in patient’s overall health to appropriate care team, routing patient escalations accurately

CCM patients are acknowledged and touched weekly. Complications are identified and face to face encounters are scheduled according to protocol.

Medication dosing, frequency and discontinuations are reconciled with patients. All allergies, medication and non-medication related, are entered and/or updated in the EMR. Any new issues identified and/or non-compliance to care plan is communicated to appropriate care team.

• Answers incoming calls in a timely manner
• Sends and answers weekly check-ins with CCM patients
• Update Phamily system to support time spent with patient
• Update patient’s status in EMR 
• Demonstrates proficiency in the use of hospital EHR systems
• Demonstrates proficiency in the use of Allscripts PM and Allscripts EMR
• Updates demographic/insurance/contact information in Allscripts PM
• Demonstrate proficiency in use of Excel, Word and Teams
• Schedules appointments using appropriate appointment type
• All incoming calls and texts are reconciled and documented accordingly utilizing the “Stopwatch” and or “task” functionality.
• Responsible for ongoing Communication with provider teams and patients. Scheduling of appointments utilizing the appropriate appointment type(s).
• Hospital systems are accessed obtaining established protocol records and are indexed appropriately.

Requirements

Education: High School Diploma or general equivalency diploma (GED). Completion of a medical assistant training program through an accredited school or graduate of an accredited nursing program.

Experience: Minimum of three years’ experience working in a medical facility as a medical assistant/nurse.

Certification: CMA/RMA - Medical assistant certification has been maintained. Nurse – must hold a current and valid North Carolina license. Current CPR certificate.

Technical Skills: Knowledge of clinical processes, healthcare systems, structure and functions; and community resources. Familiarity with clinic policies and procedures. Knowledge of information that must be conveyed to patients and families. Knowledge of legal and ethical considerations related to patient information. 

Management Skills: None required

Personal Qualities: Professional presentation. Excels at working independently. Possesses confidence and skill in influencing and engaging patients to participate in their ongoing health care needs. Proficient at multi-tasking. Customer service focused and responsive to customer’s needs, energetic, respects confidentiality, proactive and pays attention to detail. 

Technology Skills: Proficient in Word, Excel, EMR’s, Outlook. Competent in Learning Management Systems.

Communication Skills: Excellent communication skills, able to communicate effectively at all levels of the organization; able to effectively resolve conflict situations, able to work collaboratively with physicians, directors, managers and staff. Able to promote free-flowing 2-way communication with patients and their support systems.

Equipment Operated: Standard office equipment including computers, fax machines, copiers, printers, telephones, etc. Standard medical exam/office equipment including computer hardware and software such as Allscripts, Touch works and timekeeping. Basic medical equipment knowledge.