Patient Coordinator Home Health

Atrium Health; Macon (GA); On-site; USD 42,000 - 55,000; Full time

Job summary

Atrium Health is seeking a Care Management team member to engage medically vulnerable patients, provide education, and coordinate care across the health system.

You will communicate with patients and caregivers, conduct screenings for social determinants of health, and help navigate referrals to community-based services and support programs. Strong organizational and interpersonal skills are essential.

Qualifications

• High School Diploma or GED required; strong verbal and written communication skills.
• Familiarity with Microsoft Office and basic computer skills.
• Ability to respond quickly to changes in community and clinic settings.

Responsibilities

• Engages medically vulnerable or chronically ill patients to support health goals with education and encouragement.
• Maintains relationships with Care Management team to personalize patient health management.
• Performs screenings for social determinants of health and refers as appropriate.
• Communicates with patients and caregivers in person, by phone and electronically.
• Monitors biometrics, medication adherence, barriers, and connects patients with resources.
• Facilitates referrals to services and supports patient access.
• Coordinates care across the continuum while maintaining confidentiality.

Skills

Communication

Motivational Interviewing

Patient education

Care coordination

Advocacy

Education

High School Diploma or GED

Tools

Microsoft Office

Job description

• Engages a population of medically vulnerable or chronically ill patients in their care, assisting them through the process of working towards better health by providing support, encouragement and education.
• Communicates and maintains relationships with other members of the Care Management team to promote a lifelong, proactive partnership with patients to enhance and personalize management of health-related needs.
• Completes screenings on patients for social determinants of health needs and refers as appropriate.
• Communicates with patients and caregivers in person, by telephone and via electronic means.
• Utilizes Chronic Disease Management protocols, under the direction of clinical teammates; monitors patient-reported biometrics, medication adherence, reported challenges/barriers and promptly connects the patient with the appropriate resources, and/or notifies the patient's care team for additional follow-up.
• Provides customized, evidence-based patient education in a variety of areas, under the guidance of clinical teammates and based on the patient's readiness to change; includes but not limited to weight management/exercise, tobacco cessation, stress reduction and chronic disease self-management. Uses Motivational Interviewing skills to engage and assist patient/parent/family.
• Assists providers' offices/ medical home staff with member specific missed appointments through outreach and scheduling.
• Advocates and facilitates referrals to gain access to services and resources for patients, including patient assistance programs, community-based services and mental health support.
• Assists with the coordination of care across the care continuum and transitions of care (including home care, outpatient care, ER care, and hospital care) while maintaining strict patient confidentiality.
• Advocates to help those who frequently access inappropriate levels of care.
  

Essential Functions

• Engages a population of medically vulnerable or chronically ill patients in their care, assisting them through the process of working towards better health by providing support, encouragement and education.
• Communicates and maintains relationships with other members of the Care Management team to promote a lifelong, proactive partnership with patients to enhance and personalize management of health-related needs.
• Completes screenings on patients for social determinants of health needs and refers as appropriate.
• Communicates with patients and caregivers in person, by telephone and via electronic means.
• Utilizes Chronic Disease Management protocols, under the direction of clinical teammates; monitors patient-reported biometrics, medication adherence, reported challenges/barriers and promptly connects the patient with the appropriate resources, and/or notifies the patient's care team for additional follow-up.
• Provides customized, evidence-based patient education in a variety of areas, under the guidance of clinical teammates and based on the patient's readiness to change; includes but not limited to weight management/exercise, tobacco cessation, stress reduction and chronic disease self-management. Uses Motivational Interviewing skills to engage and assist patient/parent/family.
• Assists providers' offices/ medical home staff with member specific missed appointments through outreach and scheduling.
• Advocates and facilitates referrals to gain access to services and resources for patients, including patient assistance programs, community-based services and mental health support.
• Assists with the coordination of care across the care continuum and transitions of care (including home care, outpatient care, ER care, and hospital care) while maintaining strict patient confidentiality.
• Advocates to help those who frequently access inappropriate levels of care.
  

Physical Requirements

Work requires walking, standing, sitting, lifting, reaching, bending and stooping. Must lift a minimum of thirty-five pounds shoulder high. Ability to travel/ drive between various locations is required for this position. Requires frequent verbal and written communication in English. Must have intact sense of sight, hearing and finger dexterity. Occasional intermittent noise and exposure to conditions such as dust, fumes and chemicals.

Education, Experience And Certifications

A High School Diploma or GED is required. Must possess excellent verbal and written communication skills. Must possess basic computer knowledge and ability to use Microsoft office applications. Strong organizational skills. Must have effective interpersonal skills. Must be able to respond quickly to changes in community and clinic settings.