Healthcare Advocate for Ambulatory Care
4 days ago
About LifeBridge Health
">We are one of the largest healthcare providers in Maryland, with 13,000 team members, striving to CARE BRAVELY for over 1 million patients annually.
">Job Summary:
">The Community Care Coordinator will promote health and welfare through face-to-face and phone outreach, ensuring timely access to services while respecting patient rights and wishes. This role is a member of the Interdisciplinary Team (IDT) caring for assigned patients, identifying their needs, and linking them with community resources.
">Responsibilities:
">- ">
- Contact patients, caregivers, and families to ensure preventive services are received by assigned patients.">
- Decrease identified care gaps by working with primary care offices to obtain timely appointments for assigned patients, including post-hospital discharge and annual wellness visits where appropriate.">
- Understand and apply principles of population health management to identify patients with uncontrolled chronic conditions and/or rising risk indicators and refer to the Community Care Manager accordingly.">
- Provide care coordination services for patients requiring chronic care management.">
- Ensure that appropriate patients receive annual physical exams and/or annual health risk assessments (HRAs), including completion of required documentation by payer contract.">
- Evaluate and refer patients to the Community Care Manager when acuity changes.">
- Follow treatment plans written by providers and/or the Community Care Manager.">
- Assess patient safety needs in their home environment and assist the IDT in evaluating patient needs to facilitate self-management skills.">
- Lead IDT discussions in home management of assigned patients, facilitating home care referrals as needed.">
- Facilitate discussion with patients and family members on advance directives.">
- Link patients with community resources, such as prescription assistance, and aid in navigating social and health services, including enrollment in Medicaid, Medicare, and other insurance plans.">
- Assess and assist patients' safety needs in their home environment, ordering necessary equipment to promote independence.">
- Assist with medication management, setting up medication boxes if needed.">
- Refer patients or family members to community resources for housing or treatment to support recovery from chronic illness and follow-up to ensure service efficacy.">
- Educate and support family members in understanding, dealing with, and supporting patients with chronic illnesses and end-of-life practices.">
- Interview clients about activities of daily living to determine needs and link with community resources where appropriate.">
- Review and update provider and Community Care Manager information on patients' living conditions and ability to adhere to plan of care and coordinate treatment goals.">
- Assess, monitor, and evaluate patient progress in the home with respect to treatment goals.">
- Document findings in the healthcare record according to System-approved protocols.">
- Collect data, maintain records, develop, and utilize assessment and measuring tools relative to patient care and wellness practices.">
- Obtain and coordinate access with primary care providers and other specialty providers, ensuring necessary records and documentation of referrals are completed and reconciled.">
- Educate patients on available resources for primary and acute care, as well as alternative community programs and services promoting sound health, lifestyle, and well-being.">
- Schedule timely and appropriate office and follow-up visits at or with other healthcare providers, such as dentists, public health, social services, or outreach workers needed to provide comprehensive and quality care.">
Requirements:
">- ">
- Licensed Practice Nurse or Certified Medical Assistant or trained Patient Care Assistant with 2-3 years acute care and/or ambulatory practice experience.">
- Preferably with experience working with care managers from acute care settings or health insurance and/or other payer entities.">
- Good verbal and communication skills and organizational skills are a must.">
- Competency in electronic medical records is desirable.">
- Bilingual preferable (market specific).">
Estimated Salary Range: $17.00-$26.00 per hour, based on experience.
">About Us: At LifeBridge Health, we strive to provide exceptional care to our patients and communities. Our commitment to CARE BRAVELY encompasses our values and mission to deliver compassionate, innovative, and personalized care.
">Apply Now: If you are passionate about delivering high-quality care and making a difference in the lives of others, please submit your application. We look forward to reviewing your qualifications and discussing this opportunity further.
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