GENERAL DESCRIPTION OF POSITION

Performs function necessary to better coordinate and manage patient care. Performs functions to enhance quality, address prevention, increase compliance, improve patient satisfaction, maximize efficiency of providers/nurses, and meet Accountable Care Organization, Primary Care Medical Home (PCMH), and Meaningful Use indicators. Collaboration with Provider and other members of the PCMH team to provide comprehensive care. Serves as a liaison between the Providers and the clinical staff in patient care related issues. Follows Su Clinica (SC) policies and procedures. Assists in the delivery of primary care and patient care management. Provides assistance and guidance to clinical staff. May be required to work evenings and weekends as needed. When assessing the patient, the age of the patient is taken into consideration. Performs other duties as assigned. Direct and perform duties to ensure that patient has a pleasant and satisfactory experience in the method in which their healthcare is delivered, managed, and coordinated with internal and external entities while encouraging the patients’ participation in decision making. The position requires total support of the PCMH principles, policies and procedures. This position may require you to float to other departments within SC besides your assigned primary location and/or to another SC location.

ESSENTIAL JOB FUNCTIONS

• Creates and updates personalized care plans for patients
• Collaborates with patients’ families/identified support system in developing treatment plans
• Interacts with healthcare providers (HCP) to facilitate patients’ treatments
• Ensures patients’ treatment requirements are met
• Suggests alternative treatment plans when patient’s services request do not meet medical necessity
• Instructs and educates patients on procedures, HCP instructions, and referrals
• Refers patient s to social services as needed
• Conducts regular follow ups with patients to evaluate progress towards goals, promote continuity of care, and ensures improved outcomes
• Maintains accurate records of case management activities
• Evaluates all elements of care management for continuous quality improvement initiatives and participates in SC initiatives
• Participates in the interview process to hire new Care Manager (CMs)
• Schedules meetings with all caregivers, doctors, multidisciplinary team involved in a patient's care as needed
• Maintains an information data stream on multiple patients
• Oversees the implementation of a patient's medical plan
• Identifies problems ahead of time and initiate appropriate actions
• Identifies conflicts in patient care and make judgement calls as to the best path forward
• Ensures all involved on the multidisciplinary team to include the patient and/or support system are up to date on the latest tests results and information
• Abides by operational, procedural or policy changes
• Ensures submission of required documentation in a timely manner
• Serves as a liaison between the provider, other clinic departments, and the nursing unit staff
• Reports issues of operational concern to the Chief of Nursing in a timely manner

• Participates in committees, projects and performance improvement initiatives
• Sets-up for procedures and assists the provider as needed
• Participates in providing training/education to SC employees or students when requested
• Ensures new employees are properly oriented
• Participates in SC community activities.

• Approaches patient care as a multidisciplinary team involving clinical and non-clinical staff (i.e. Physicians, mid-levels, educators, appointments staff) to achieve patient care objectives
• Attends SC educational programs, committee meetings or other meetings as required
• Submits required documentation in a timely manner (credentialing requirements, license renewals, certifications, continuing nurse education attendance, etc.)
• Able to bend, stretch, stoop, stand, sit, and lift a minimum of 20 pounds
• Responsible for their own safety as well as the safety of others
• Cross trains to work in other departments or other duties as assigned by supervisor /management

Patient relationship:

• Compliance with all Health Insurance Portability and Accountability Act (HIPAA) regulations in and outside of the Clinic
• Serves as a patient’s clinical advocate
• Greets and welcomes the patient in a pleasant, respectful, culturally and linguistically appropriate manner
• Assures patient questions are answered in a positive and cordial manner
• Assures the patient has an understanding of all communications
• Performs patient call backs in a timely manner and documents in the electronic medical record (EMR)
• Ensures patients have a pleasant and satisfactory experience in the manner in which their health care is delivered, managed, coordinated with both internal and external entities and in which the patient participates in decision making
• Collaborates with CM Team, patient, family members, or identified support system to enhance their understanding of the treatment plans on the disease process to include identification of early signs of decline in condition
• Ensures patient and their care givers/support system understand establishing self-management goals and plans in a culturally and linguistically appropriate manner using motivational interviewing, health literacy promotion, and other evidence based tools

Management of patients care:

• Discusses the patient’s needs and guides them to meet their needs by assisting in setting self-management goals
• Ensures optimization of the components of care coordination and care management to improve patient’s healthcare experience and outcomes by utilizing care coordination and care management tools, criteria, and protocols
• Provides patient with chronic and acute conditions the support, education, and assistance in the prevention and/or maintenance of their disease and/or health and wellness state and increase patient’s compliance
• Facilitates telephone consultations, provider visits, or face to face visits with patients or care givers/support system for care coordination and care management, assess needs, and/or educates the patient
• Instructs on methods of health promotion and disease prevention in accordance to individualized needs
• Identifies barriers impacting the patient care and refers to appropriate support systems such as social workers, wellness counselors, etc.
• Reviews activities that occur during the patient’s hospital stay, community agencies, or at home to coordinate and manage patient’s care
• Reviews discharge planning and coordinates discharge needs with facility, care givers/support system, and patients
• Assists with refills, reviews all patient medications as per protocols
• Reinforces to the patients the importance of keeping appointments or communicating changes in their appointments
• Participates in quality improvement projects aimed at improving patient care outcomes for patients and follows all SC policies and procedures
• Prepares tracking reports regarding hospital admissions and primary care team
• Assumes floor duties if coverage needed

Manages patient information:

• Performs pre-visit chart reviews for required health indicators, vaccines, labs, etc. and places report results in charts
• Asks the required intake questions for a proper assessment and evaluation of higher level of care management support
• Verifies the patient and/or family member/support system discharge and follow up questions have been addressed and appropriate education materials provided and documented in the EMR
• Schedules tests or treatments are as requested

Team communication:

• Participates in multidisciplinary teams, huddles to coordinate care, scheduling and follow ups along with the provider and front desk clerks to prepare patients that are scheduled; review opportunities for same day access; and alerts other disciplines for patients and families with and without special needs
• Supports the Primary Care Provider in implementing the integrated plan to achieve desired outcomes and to satisfy contractual/regulatory requirements
• Precepts new SC CMs or students
• Communicates patient’s problem/complaint to the provider
• Collaborates simultaneously with provider to maximize disease prevention and reinforce patient follow through with provider’s orders and instructions
• Identifies high risk patient for disease management and care coordination and works with patients and the primary care team to establish a plan of care to meet each patient’s needs
• Refers patient to appropriate resources/referrals, social services, pharmacy, laboratory, etc.

Demonstration of safe and professional conduct:

• Performs duties within the scope of practice as delegated by provider through the use of approved standing orders and or protocols
• Maintains a friendly environment for self and others
• Responds to emergency situations as per training
• Refrains from texting and speaking on the cell phone while on duty
• Refrains from informal communication with patients and others
• Attends work on time when scheduled in accordance with SC leave policy
• Submits required documentation in a timely manner (credentialing requirements, license renewals, certifications, continuing nurse education attendance, etc.)

KNOWLEDGE, SKILLS, AND ABILITIES

• Knowledge of practice level procedures, techniques, and practice of patient care
• Knowledge and skilled in use of computer and computer software (EMR, Microsoft Word, Excel, etc.) programs as necessary and telephone system
• Knowledge of community resources
• Knowledge of the Chronic Care Model
• Skilled in excellent customer service
• Ability to complete basic/intermediate math computations and medical math conversions
• Ability to examine documents for accuracy and completeness
• Ability to maintain a flexible work schedule
• Ability to maintain an effective and professional working relationship with the public and co-workers
• Ability to maintain client, office confidentiality and abides by confidentiality expectations and HIPAA guidelines
• Ability to prepare records in accordance to detailed instructions
• Ability to read, write and speak in a clear, accurate and professional manner; includes active listening skills and understanding medical terminology
• Ability to work in a fast paced environment.
• Ability to work with medical equipment to include but not limited to: EMR and manual vital signs measurement, auditory and visual examinations, oxygen and suction apparatus, peak flowmetry
• Able to bend, stretch, stoop, stand, sit, and lift 20 pounds
• Able to show excellent interpersonal skills reflecting clarity, diplomacy and communicates accurately and effectively with all levels of staff and management
• Ability to communicate concerns to appropriate personnel using tact and diplomacy
• Ability to interpret (explain the meaning of spoken words)and translate (to write) for the provider when necessary preferred
• Ability to multitask while assisting numerous patients
• Good analytical and problem solving abilities
• Good written and verbal communication skills
• Ability to fully comply with the enhanced infection control requirements of the clinic

MINIMUM QUALIFICATIONS/CERTIFICATES/LICENSES/REGISTRATIONS REQUIRED

• A current Texas LVN license
• Minimum of 2 years clinical experience in a hospital or clinic setting
• Two years clinical experience as care manager preferred
• Must be current with BLS/CPR certified
• Experience in working with the public preferred
• Must be computer literate; bilingual (English/Spanish) preferred
• This position requires an initial N95 mask fit testing and annual test fitting thereafter unless there is a significant change during the year that requires retesting prior to the annual fit testing.

SPECIAL INSTRUCTIONS: Employee must provide transportation. If employee operates a personal motor vehicle in the performance of their official duties, the employee must possess a current valid Texas driver’s license for the appropriate type of vehicle and Texas Liability insurance. This position requires that an employee’s driving record be verified with law enforcement to ensure compliance with SC’s driving policy.