Care Management Outreach Coordinator- Star Community Health Rural Health
St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.
The Care Management Outreach Coordinator (CMOC) will be responsible for assisting patients and their caregivers navigate and access community services, other resources, and adopt healthy behaviors. The CMOC supports providers, and the care managers through an integrated approach to care management and community outreach. The CMOC provides social support and informal counseling, advocates for individuals and community health needs with government agencies or health service providers, supports telehealth visits and performs home visits and health screenings.Job Duties and Responsibilities:
- Coordinates care with patients, providers, and care plan to identify barriers to meeting care plan goals by actively participating in care team huddles and care coordination meetings.
- Develops and maintains relationship with community agencies and resources.
- Responsible for establishing trusting relationships with patients and their families while providing general support and encouragement to the patient through telephonic and community outreach
- Perform home safety evaluations and health screenings.
- Assist patient in scheduling appointments and diagnostics.
- Performs appropriate health coaching related to chronic illness and compliance.
- Telehealth visit assistance with technology, gathers self-monitoring vital signs, and preparing medications or medication list for review with the provider.
- Utilizes motivational interviewing technique when outreaching the patient or caregiver.
- Attend provider and community appointments with patients as needed.
- Provide referrals for services to community agencies as appropriate.
- Maintain accurate, complete, and consistent documentation in the electronic medical record.
- Assist patients with completing applications and registration forms.
- Maintains expertise in telehealth procedures, participates in staff meetings, participates in network and/or department committees or special projects as assigned.
- Maintain assigned competencies (Athena Forum, CHW webinars, journal reviews and self-study)
- Participates in peer educational presentations.
- Attending scheduled rounding and site visits.
- Asses the need for referrals and determine eligibility for services, according to government and local program guidelines.
PHYSICAL AND SENSORY REQUIREMENTS:
Must have the ability to sit for 2 hours per day, and up to 1 total consecutive hour. Must be able to stand for 6 hours total per day and up to 4 consecutive hours. Must be able to walk six total hours per day and up to 30 total consecutive minutes. Must have the ability to frequently use fingers and hands. Must have the ability for touching as it relates to feeling objects by touching with skin, particularly that of the fingertips. Must have the ability for hearing as it relates to normal conversation, high frequency, and low frequency hearing sounds. Must have the ability for seeing as it relates to general vision, near vision, color vision, and peripheral vision.
EDUCATION:
High School Graduate/GED with 3 years of patient care or community resource experience required.
Associates Degree with 2-year patient care or community resource experience preferred.
Community Health Certificate preferred - Required to obtain within one year
Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!
St. Luke's University Health Network is an Equal Opportunity Employer.
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At St. Luke's, we pride ourselves on having a dedicated team that values skills, experience, and compassion in every employee. We believe that our employees are our most valuable asset, and together, we are committed to delivering excellence in patient care. As a Care Management Outreach Coordinator for Star Community Health Rural Health, based in Bethlehem, you'll play a pivotal role in helping patients and their caregivers navigate community services and adopt healthy behaviors. Your mission will not only involve providing social support and informal counseling but also collaborating with providers and care managers to ensure a seamless approach to healthcare. You'll assist in telehealth visits, perform home visits, and conduct health screenings, all while advocating for individuals' health needs. Building trust with patients and families during telephonic and community outreach will be crucial, as well as facilitating appointments and health coaching related to chronic illnesses. By utilizing motivational interviewing techniques, you will empower patients on their journeys to better health. This position offers the chance to work closely with community agencies and resources, actively participate in care coordination meetings, and maintain accurate documentation in electronic medical records. With a focus on continual learning and expertise in telehealth procedures, you’ll engage in important staff activities, educational presentations, and site visits, making a real difference in the lives of those in our community, regardless of their ability to pay. If you're ready to embrace a rewarding career at St. Luke's, we would love to hear from you!
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