Become part of the Beebe team - an inclusive team positioned in a vibrant, coastal community. Enjoy a fulfilling career as you support the health of our patients and a team focused on excellence.

After completing the probationary period of 90 days of on-site orientation, training and work at the Population Health building, Carpenter's Way, Lewes, DE, this position will work in a remote, home office setting.

This individual is responsible for providing phone follow-up and care coordination services for Beebe Medical Group (BMG) attributed and unassigned patients discharged from Beebe Healthcare inpatient, walk-in, or emergency department setting.

The focus of the role is on improving the patient experience of care, improving population health and transitions of care, ensuring high quality outcomes and reducing unnecessary, avoidable utilization of the ED and inpatient hospitalizations.

Strong customer service and communication skills, and vast knowledge of area community resources and services is required.

Assists with Beebe Population Health programming and implementation as directed, working with patients, families, caregivers, and providers as part of an interdisciplinary team to provide care coordination.

Ability to assess, plan, implement, coordinate, monitor, and evaluate health care options and services with the goal to optimize patient health status across the care continuum.

Capacity to integrate best practices, chronic disease prevention guidelines, protocols and other metrics in development of treatment plans that are patient-centered, promote quality and efficiency in the delivery of care.

Responsible for facilitating clinically integrated care and maintaining current knowledge of transition of care best practices.

• • Identifies, tracks, and performs outreach and tracks special populations, including high-risk patients and other populations due for preventive or chronic care services
  • Reaches out to high-risk patients as identified through risk stratification to ensure any social determinants of health (SDOH) are identified and addressed
  • Assists patient and families to identify social, medical and financial needs and barriers.
  • Identify opportunities to close gaps in care for patients
  • Develop/run monthly reports of preventive and chronic care that is due and complete outreach to patients to schedule/notify
  • Identification and Solutions for Patient Barriers to Care
  • Navigates referrals to the CHWs to facilitate the support of patient care needs such as transportation, insurance, housing, food, and other community resources to include attaining or completing applications for such services.
  • Work with patients and community-based organizations (CBOs) to identify barriers to care with the goal of finding solutions and resources to remove barriers to care.
  • Leverages local agencies throughout the community to assist patients with getting referrals for the services they need
  • Address patient's social determinants of health (SDoH)
  • Help patients obtain the care they want and need when they need it
  • Continuously add to current list of community resources for patients.
  • Assist patients with navigating the healthcare system.

• Two years minimum experience in health care- preferably primary care, case management/care coordination, and/or acute care.
• Knowledge of the community, challenges in navigating the health care system, and provision of patient-centered care.
• Excellent communication skills and the ability to work collaboratively with others. Computer proficiency and familiarity with Electronic Health Record documentation required.
• Must be a Delaware resident preferably located within Sussex County

Education:

Essential:

Associate's Degree in healthcare related field (High School Diploma with at least two years of equivalent experience will be considered)

Preferred: Social Work Degree or equivalent

Essential:
* Clear Communication Skills Both Written And Verbal* Able To Keep Confidential Information Regarding Patients, Team Members* Able To Withstand Crisis Situations* Has Skills To Provides Customer Service To Patients, Team Members And Visitors* Knowledge And Experience With Electronic Health Records

Nonessential:* RN Diploma/RN Graduate Program* Associates Degree in related field