Job Description

Works with a multi-disciplinary team of health care providers to manage targeted patient populations to achieve efficient and effective care delivery through disease management. Works with patients who have chronic conditions or at risk for a chronic condition in-person, by telephone or via electronic means to educate, counsel and coordinate care across the health care continuum. Guides and facilitates action-oriented goals to improve clinical outcomes, empower patient using evidence-based guidelines, reduce gaps in recommended evidence-based care and reduce frequent hospital admissions and re-admissions. If operating in the PASO capacity, team member will utilize both the Spanish and English languages, work collaboratively with PASOs, Access Health and a multi-disciplinary team of health care providers to manage Hispanic patients identified with chronic conditions or at risk for chronic conditions to achieve efficient and effective care delivery through disease management. Promotes consistency in long-term management approaches and optimize treatment for patients with targeted conditions. Achieves optimal levels of wellness in the targeted patient populations through participation in the development of a plan of care that improves the patient’s basic understanding of his/her disease process under the supervision of a Care Manager and in conjunction with patient/family, physicians and other health care team members, increasing provider awareness and participation with recommended treatment modalities, Monitoring patient’s condition and addresses lifestyle issues, Participating in the transition of patients from disease management to care management when specific patient indicators exceed the established threshold, Attainment of increased compliance with treatment regimen, Uses knowledge of health system and community resources to facilitate achievement goals, Provides health education, identifies barriers to attainment of self-management goals and develops strategies to overcome, Reduces emergency room utilization and frequency of inpatient admissions, Reduces and delays late-stage disease manifestations. Conducts outreach calls to disease management patients to document non-clinical and clinical data for patient assessment, provides health education, engages member in appropriate self-care techniques, shared decision-making and knowledgeable use of medications. Participates in the development and execution of the plan of care and disease specific interventions. Works with health system staff, care management and partners as necessary to provide continuity of care. Facilitates referrals to other disciplines and community-based programs as appropriate to improve patient outcomes. Utilizes and incorporates knowledge of efficiency and effectiveness indicators (PHQ-9 and Patient Activation Measure) when creating plan of care. Increases knowledge of best practices, self-management, and standards of care into practice. Documents in the medical record and other established platforms, accurately reflecting collaborative care planning, intervention and evaluation against defined targets and goals. Performs other duties as assigned.

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