Patient Coordinator Home Health

Atrium Health; Macon (GA); On-site; USD 42,000 - 66,000; Full time

Job summary

Atrium Health is seeking a Care Management professional to engage medically vulnerable or chronically ill patients, guiding them toward better health through support, education, and coordinated care across the continuum.

You will work with care teams, conduct screenings for social determinants, communicate with patients and caregivers, and help navigate resources, appointments, and referrals while safeguarding confidentiality.

Qualifications

• High school diploma or GED required.
• Excellent verbal and written communication skills.
• Basic computer knowledge and ability to use Microsoft Office.
• Strong organizational and interpersonal skills.

Responsibilities

• 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.

Skills

Verbal communication

Written communication

Interpersonal skills

Basic computer skills

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.