Community Wellness Coach - Primary Care - FT - Days - Hollywood

Summary

Works collaboratively with physicians, staff, and other health care professionals to provide care coordination across the health continuum for all assigned patients ensuring that safety, best practice, and high quality standards of care are maintained. Serves as a mentor, educator, and advocate for personal health and wellness.

Responsibilities

• Adheres to CMS compliance regarding Medicaid/Medicare regulations and ensures regulatory compliance.
• May consult and/or train new staff, students, and interns.
• May serve as backup for the Medical Assistant in performing basic medical care and exams.
• Delivers general and specialized education on preventive and chronic care conditions measures, including weight and stress management, risk prevention and reduction, and living with specific health conditions.
• Responsible for regulatory compliance of Healthcare Effectiveness Data and Information Set (HEDIS) measures monitored and reviewed quarterly to ensure care gap metrics are achieved.
• Works with physicians to reduce emergency room utilization for avoidable visits through outreach and providing alternative resources.
• Assists patients in the comprehension of complex instructions and facilitates conflict resolution.
• Uploads and tracks patient records in Avality to ensure patient population health continuum is compliant based on HEDIS measurements.
• Provides assessment and coaching to individuals to help them develop and achieve wellness goals, including personal empowerment, lifestyle changes, and behavior modification.
• Assesses for Social Determinants of Health and provides community resources to leverage social barriers.
• Interviews and assesses patients and/or family, caregivers, and/or legal representatives.
• Provides outreach to patients and families to ensure care coordination.
• Determines, prioritizes, provides and/or arranges for needed internal and external services.
• Obtains medical authorizations and schedules primary care, specialist care, lab, and diagnostic testing appointments.
• Assists with the identification, determination and need for systems, process workflows, equipment and supplies, such as Remote Patient Monitoring Devices (BP machine) and Colorectal Cancer Screening Kits.
• Generates and analyzes patient reports reviewed by senior staff at patient re-cap meetings along with key business stakeholders (Physicians, Pharmacists, and Nurses).
• Independently analyzes processes and high-risk patient information, identifies problems and trends, and develops effective solutions and strategies.
• Facilitates care plans, provides updates to the team, and documents efforts.
• Uses various forms of communication methods including face-to-face, telehealth, email, and mail.
• Works closely with physicians and the multidisciplinary care management teams.

Education and Certification Requirements

• Accredited Program: Medical Assistant (Required)
• BLS Certification (American Heart Association or Red Cross) required within 6 months of hire
• Fingerprint Screen - Florida Department of Children & Family (DCF)

Additional Job Information

Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Excellent communication and presentation skills effective in working with all levels of clinicians. Self-starting, meticulous, and forward thinking with demonstrated case management and organizational skills. Illustrated knowledge of both healthcare operations as well as the health insurance/health plans industry and Epic expertise. Knowledgeable in Excel, Word, and PowerPoint. Must be able to work independently with minimal supervision.

Required Work Experience

Graduate of an accredited Medical Assistant/EMT program with one (1) year of experience.