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Care Management Outreach Coordinator

3 months ago

Allentown, United States St. Luke's University Health Network Full time

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset Individually and together, our employees are dedicated to satisfying the mission_ of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care._

The Care Management Outreach Coordinator (CMOC) will be responsible for assisting patients and their caregivers navigate and access community services, other resources, and adopt healthy behaviors. The CMOC supports providers, and the care managers through an integrated approach to care management and community outreach. The CMOC provides social support and informal counseling, advocates for individuals and community health needs with government agencies or health service providers, supports telehealth visits and performs home visits and health screenings.

Job Duties and Responsibilities:

- Coordinates care with patients, providers, and care plan to identify barriers to meeting care plan goals by actively participating in care team huddles and care coordination meetings.
- Develops and maintains relationship with community agencies and resources.
- Responsible for establishing trusting relationships with patients and their families while providing general support and encouragement to the patient through telephonic and community outreach
- Perform home safety evaluations and health screenings.
- Assist patient in scheduling appointments and diagnostics.
- Performs appropriate health coaching related to chronic illness and compliance.
- Telehealth visit assistance with technology, gathers self-monitoring vital signs, and preparing medications or medication list for review with the provider.
- Utilizes motivational interviewing technique when outreaching the patient or caregiver.
- Attend provider and community appointments with patients as needed.
- Provide referrals for services to community agencies as appropriate.
- Maintain accurate, complete, and consistent documentation in the electronic medical record.
- Maintains expertise in telehealth procedures, participates in staff meetings, participates in network and/or department committees or special projects as assigned.
- Maintain assigned competencies (Athena Forum, CHW webinars, journal reviews and self-study)
- Participates in peer educational presentations.
- Attending scheduled rounding and site visits.
- Asses the need for referrals and determine eligibility for services, according to government and local program guidelines.

PHYSICAL AND SENSORY REQUIREMENTS:
Must have the ability to sit for 2 hours per day, and up to 1 total consecutive hour. Must be able to stand for 6 hours total per day and up to 4 consecutive hours. Must be able to walk six total hours per day and up to 30 total consecutive minutes. Must have the ability to frequently use fingers and hands. Must have the ability for touching as it relates to feeling objects by touching with skin, particularly that of the fingertips. Must have the ability for hearing as it relates to normal conversation, high frequency, and low frequency hearing sounds. Must have the ability for seeing as it relates to general vision, near vision, color vision, and peripheral vision.

EDUCATION:
High School Graduate/GED with 3 years of patient care or community resource experience required.

Associates Degree with 2-year patient care or community resource experience preferred.

Community Health Certificate preferred - Required to obtain within one year
- St. Luke's University Health Network is an
- Equal Opportunity Employer.