Patient Care Liaison

2 weeks ago

Columbus, Ohio, United States Cityblock Full time
Job Overview:
Position Summary:

Cityblock's Transition of Care (TOC) initiative is designed to assist members in effectively managing their recovery journey after being discharged from acute care and hospital environments. As a TOC Care Coordinator, your primary responsibility will be to connect with members to arrange post-discharge consultations, facilitate care coordination, and enhance engagement to prevent hospital readmissions.

Engagement Responsibilities:
  • Receive assignments of members from the TOC team.
  • Initiate contact with members and caregivers to schedule post-discharge visits, outlining the objectives and expectations of the TOC program.
Assessment and Intake:
  • Conduct assessments in accordance with established protocols and as directed by the TOC Registered Nurse Care Manager (TOC RNCM).
Case Review and Care Planning:
  • Assist the TOC RNCM in discharge planning by:
    • Collaborating to create post-discharge care plans that address identified needs and obstacles for a seamless recovery.
  • Support members in achieving their care plan objectives by:
    • Presenting preliminary goals and resources to address social and care coordination needs.
    • Guiding members to fulfill their care plan goals and coaching them to completion.
    • Focusing on members' objectives, risk mitigation, proactive engagement, provider collaboration, and addressing social determinants of health.
  • Participate in case discussions following member discharge to strategize on readmission prevention.
  • Work with the TOC RNCM to transition care to longitudinal support at the conclusion of the TOC program.
  • Collaborate with the TOC team to assess the need for escalated member care.
Follow-Up Activities:
  • Conduct weekly check-ins with members to monitor post-discharge care plan needs and progress.
  • Facilitate care coordination, addressing benefits, social needs, and external care with members, caregivers, internal teams, and external providers.
  • Provide routine non-clinical education on preventive care topics.
  • Respond to member needs promptly and delegate tasks as necessary.
  • Meet with members in various community settings as required, acting as an extension of the care team for non-clinical needs.
  • Perform screenings for emerging needs.
  • Refer members to the TOC RNCM for clinical needs while engaging other internal teams as needed.
  • Ensure closure on internal referrals.
Operational Duties and Reporting:
  • Utilize care facilitation tools, electronic health records, and scheduling systems to collect data, document member interactions, organize information, track tasks, and communicate effectively with your team, members, and community resources.
  • Monitor TOC metrics for assigned members and log new TOC events along with follow-up metrics.
Qualifications:
  • High School Diploma.
  • 1-2 years of experience in community care or care coordination is required.
  • Valid Driver's License and access to a vehicle for daily use.
  • Proficient in using technology to assist members remotely (telephone, text, virtual platforms).
  • Familiarity with scheduling platforms for accurate appointment management.
  • Experience with electronic health record systems and care facilitation platforms for precise documentation.
  • Skilled in collecting member clinical and demographic data and documenting it promptly.
  • Knowledgeable in Motivational Interviewing and Trauma-Informed Care principles.
  • Strong problem-solving abilities, capable of making difficult decisions and collaborating with team members when necessary.
  • Able to devise creative solutions to challenges within the healthcare system that hinder optimal member care and health.
  • Possess a growth mindset, with the ability to think innovatively and adapt to changing responsibilities.
  • Flexible and prepared for rapid changes and shifting priorities.
Cityblock is committed to diversity as a fundamental principle of our work and the communities we serve. We are an equal opportunity employer, regardless of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.

COVID-19 Update:

Cityblock requires all individuals hired for this position to provide proof of COVID-19 vaccination. Requests for exemptions based on valid religious or medical reasons may be submitted for consideration and will be reviewed on a case-by-case basis.

Medical Clearance for Member-Facing Roles:

Completion of Cityblock's medical clearance requirements is necessary, which may include evidence of immunity to certain diseases or an approved medical or religious accommodation.

Note:

Cityblock does not accept unsolicited resumes from external recruiters or placement agencies.

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