About this role
1. Wellness Prevention & Quality
- Collaborate with members of the health care team to assist patients with wellness to include wellness exams and healthy living habits.
- Review registry information for assisting to meet the needs of patients and provide quality of care.
- Review Quality measures and assist providers and the primary care team to meet and exceed metric benchmarks.
- Educate patients regarding wellness and prevention to achieve quality of life.
- Review value-based contract metrics to assist the primary care team to implement workflows assisting patients to achieve quality goals.
2. Care transitions/ Patient navigation
- Follow patients through the health care system assisting with transitions with primary care, specialists, and ancillary departments to ensure their understanding of treatment.
- Introduce patients to available programs –TCM (transitional care management), CCM(chronic care management), PCM (principal care management) and RPM (remote patient monitoring) to assist in self-management of chronic disease and co-morbidities
- Collaborate with the primary care team, patients, caregivers, and family to ensure patients' needs are met at the point of care.
- Assist patient with SDoH (social determinants of health) needs and allocating resources.
- Lead the primary care team to achieve health equity for all patients seen in primary care.
3. Health coaching/goal setting & care planning
- Communicate and collaborate effectively with health team members.
- Educates patients regarding chronic disease & comorbidities, assists with self-management.
- Identify and recognize abnormal symptoms/changes in patient condition. Appropriately, reports condition changes to medical provider.
- Encourages adoption of habits that are conducive to a higher quality of life.
- Utilizes Motivational Interviewing to assist patients in reaching their health care goals.
- Collaborates with patients to develop patient centered plans.
- 4. Performs other duties as assigned.