Must utilize sound medical knowledge and clinical judgement in determining patient referrals, outreach, and coordination of care to maintain patient safety and service quality. Decisions must be made with weighted consideration and awareness of the impact that they have on patient care and outcomes.

Must be organized, self-motivated and possess the ability to work autonomously to implement care coordination, case management, and identify solutions at an individual, community and system level. Will seek supervisor support when indicated and/or necessary.

 

 

Key Essential Functions and Accountabilities of the Job

• • Coordinate and deliver care that is safe, timely, effective, efficient, equitable, and patient-centered. 

  • Coordinate within and outside of the SEARHC health system to implement a consistent, effective, supportive system of care. 

  • Provide risk reduction counseling and health coaching utilizing Motivational Interviewing skills and techniques.  

  • Establish patient caseload in target communities.  

  • Track and maintain case management data.  

  • Monitor patient progress and track outcomes using SEARHC standards of performance and care.  

  • Support and strengthen working relationships with community-based service providers in rural communities through a coordinated system of care. Promote regular communication and team relationships between community-based providers, clinic staff and case management staff on a local and regional level. 

  • Maintain working knowledge of existing community services and collaboratively seek to close gaps.  

  • Advocate for patient and patient caregivers at service-delivery level, empower patient decisionmaking and self-care, and address patient needs in a timely manner.  

  • Collaborate with the medical providers and interdisciplinary team members to establish plan of care to maximize patient healthcare outcomes. Coordinate care conferences and track patient referrals within SEARHC and outside facilities.  

  • Assess, educate, coach and document patient encounters, participate in departmental and clinical improvement efforts, maintain a clean and safe working environment for self, staff, and patients, and maintain compliance with annual competencies. 

  • Identify community resources, foster partnerships, and utilize resources effectively. 

  • Performs other duties as assigned, including special projects deemed necessary to provide comprehensive health services.  

  • Assist the WISEWOMAN Women’s Health team in achieving grant requirements and goals. Provide community outreach when necessary. Perform program enrollments, annual reenrollments, required follow-up visits, patient tracking, and data entry. Participate in annual Mobile Mammo and WISEWOMAN Women’s Health Clinics.  

  • Occasional travel is required.