Patient Care Facilitator

2 weeks ago

Houston, Texas, United States Su Vida Services Inc Full time
About Us

At Su Vida Services Inc, we understand that enhancing lives requires a community united by shared values and a meaningful mission. We are a comprehensive primary care initiative designed to meet the physical, behavioral, social, and cultural needs of an underserved Medicare-eligible Hispanic senior demographic. Our goal is to elevate the quality of life for Hispanic seniors and their caregivers in communities throughout the nation.

We are fostering a compassionate and service-oriented environment that attracts, engages, values, and rewards talented individuals who share our vision, positioning us as a leading healthcare provider and an employer of choice.

What Sets Us Apart

We are a dedicated primary care, clinical operations, and support team focused on achieving health equity through an outstanding clinical and consumer experience that enhances the quality of life for individuals, families, and communities we serve. Our primary care program is customized to align with the culture, language, social needs, and overall wellbeing of the seniors we support.

Key Responsibilities

Position Overview

The Patient Care Facilitator will be instrumental in providing exceptional care to our patients at Su Vida Services Inc. Collaborating closely with the Nurse Care Manager, the Patient Care Facilitator will be tasked with performing daily patient follow-ups, managing durable medical equipment (DME) and home health orders, triaging incoming calls, obtaining hospital records for recently admitted patients, and executing various clinical clerical duties for high-risk patients. The Patient Care Facilitator will also undertake additional responsibilities as directed by the Nurse Care Manager.

Core Duties
  • Conduct daily follow-ups for high-risk patients enrolled in the Chronic Care Program.
  • Efficiently and accurately process DME and home health orders.
  • Handle inbound triage calls from patients and coordinate appropriate responses to urgent patient needs.
  • Obtain hospital records for patients recently admitted to external healthcare facilities.
  • Perform clinical clerical tasks to support the Chronic Care Program and Transition of Care Programs.
  • Assist in procedures within the Medical Assistant scope of practice for high-risk patients.
  • Work closely with the Nurse Care Manager to ensure smooth patient care delivery.
  • Identify and address barriers to care for high-risk patients.
  • Coordinate patient care progression throughout the continuum, including transitions from acute and post-acute settings to home or other transitional care facilities.
  • Communicate effectively with physicians, nursing staff, and other members of the multidisciplinary care team.
  • Facilitate the patient discharge planning process to optimize outcomes and satisfaction.
  • Monitor patient progress and intervene as necessary to ensure patient-centered, high-quality care.
  • Collaborate with external case managers and community resources as needed.
  • Actively engage in clinical performance improvement initiatives.
  • Support efforts to close care gaps and achieve Medicare HEDIS metrics.
  • Perform other tasks as assigned.
Qualifications

Knowledge, Skills, and Abilities
  • Minimum of 2 years of experience as a Medical Assistant or LPN/LVN.
  • Experience in chronic care management or a related field is preferred.
  • Excellent interpersonal and communication skills.
  • Strong organizational and time management capabilities.
  • Proficiency in Microsoft Office Suite.
  • Bilingual/Bicultural (English and Spanish) is required.
Education and Certification Requirements
  • High school diploma or equivalent.
  • Completion of a Medical Assistant program is required.
  • Certification in Medical Assisting from AAMA, CCMA, or any other nationally recognized body is required.
  • LPN/LVN license is preferred.
Our Culture & Core Values
  • Earn Trust
  • Build Relationships
  • Create Joy
  • Do Right
  • Improve Every Day
  • Move Forward
Equal Employment Opportunity (EEO) Policy

Su Vida Services Inc is committed to providing equal employment opportunities to all team members and applicants for employment, prohibiting discrimination and harassment of any kind regarding race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

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