Job Summary:

• Provide leadership and continuity of care guidance for patients with chronic diseases and/or complex disease states. 
• Uses knowledge of illness, diagnoses and treatments in comprehensive, holistic assessments of patients. 
• Performs patient teaching, patient self-management/self-efficacy coaching and planned care management. 
• Ensures coordination for specialty and other hand offs
• Utilize appropriate resources to gather data and assess patient care needs
• Makes ongoing assessments of the following domains, physio-biological, cognitive/emotional, spiritual and social, managing life with chronic disease
• Identifies problems that could lead to an emergency/crisis situation and takes appropriate action to de-escalate
• Identifies the need for and coordinates specialists/consultants
• Communicates assessment data to appropriate persons
• Assesses learning needs of patient/significant others

Skills on Resume: 

• Comprehensive Clinical Knowledge (Hard Skills)
• Patient Education and Coaching (Soft Skills)
• Care Coordination and Management (Soft Skills)
• Data Gathering and Assessment (Hard Skills)
• Holistic Patient Assessment (Hard Skills)
• Crisis Prevention and Management (Soft Skills)
• Interdisciplinary Collaboration (Soft Skills)
• Effective Communication (Soft Skills)

Job Summary:

• Documents assessment data according to clinic standards.
• Plan for and manages a panel of patients with chronic/complex disease
• Plans interventions appropriate to patients’ medical and nursing diagnoses, age, abilities and resources
• Establishes and implements learning and disease self-management plan for patient/significant others
• Documents planning process according to organizational standards.
• Provide teaching to patients/families related to patient’s diagnosis, pathology, medical and nursing treatment plans, discharge needs and health goals
• Documents each element of care per organizational and unit standards.
• Collaborate and communicate care with the patient’s PCP.
• Form partnerships with all members of the interdisciplinary team.
• Communicate with coworkers and other departments in a professional manner
• Shares appropriate information with all members of the health care team, including assistive/support personnel, in a manner that is appropriate and timely for the patient’s condition.

Skills on Resume: 

• Patient Assessment and Documentation (Hard Skills)
• Chronic Disease Management (Hard Skills)
• Intervention Planning (Hard Skills)
• Educational and Self-Management Strategies (Hard Skills)
• Health Literacy and Patient Education (Hard Skills)
• Interdisciplinary Collaboration (Soft Skills)
• Communication Skills (Soft Skills)
• Documentation Compliance (Hard Skills)

Job Summary:

• Participate in team huddles.
• Monitor patient and family satisfaction.
• Support the vision and mission of Providence Health & Services supports philosophy of patient-centered care.
• Maintain high ethical standards in practice.
• Advocate for the patient and family and protects the patient’s autonomy, dignity and decision-making rights.
• Maintain confidentiality of all patient information and holds others accountable for maintaining confidentiality.
• Deliver sensitivity to cultural diversities of patients and coworkers.
• Demonstrate sensitivity to cultural diversities of patients and coworkers.
• Identify, document and report patient safety and/or quality incidents per PMG standards.
• Support and guide ambulatory health care teams with the implementation of evidence–based practice guidelines.
• Assist in designing and implementing planned care interventions through a combination of evidence-based guideline/pathway utilization and individualized care planning.

Skills on Resume: 

• Effective Communication (Soft Skills)
• Patient and Family Advocacy (Hard Skills)
• Ethical Standards (Hard Skills)
• Confidentiality (Hard Skills)
• Cultural Sensitivity (Soft Skills)
• Patient Safety (Hard Skills)
• Support Evidence-Based Practice (Hard Skills)
• Care Planning (Hard Skills)

Job Summary:

• Work directly with patients and providers in a variety of settings (e.g., home, inpatient settings, clinic, etc.) with both health system and independent providers that are in the network to identify and engage high-risk patients and provide nursing care that is ‘hands-off’ (e.g., education, coaching, care coordination, advocacy, etc.)
• Work closely with specific patient populations (e.g., end-stage renal disease patients, COPD, CHF patients) in a variety of settings and with specialty providers in both health system and independent clinics that are in network
• Involve high-risk individuals in activities to improve health and partner with the care team to establish identified goals and action steps to focus on wellness and self-management of chronic conditions
• Provide educational resources that inform the patient’s disease management
• Develop relationships with practice care teams to operate as an extension of the provider to support high-risk patients
• Refine care plans using a thoughtful, evidence-based approach to care coordination as patients’ conditions progress or additional needs arise
• Assess and proactively address barriers to care plan compliance
• Manage internal and external customer relationships to ensure that all customer service needs are being met
• Work closely with patients and other members of the care team while maintaining effective and professional relationships
• Handle a high workload and meet deadlines with a high level of accuracy
• Assist patients with onboarding activities for Navvis programs (i.e. clinical programs, RPM, etc.)
• Work as part of an integrated team while supporting the patient

Skills on Resume: 

• Patient Education and Coaching (Soft Skills)
• Care Coordination (Hard Skills)
• Relationship Building (Soft Skills)
• Barriers Assessment and Management (Hard Skills)
• Customer Relationship Management (Soft Skills)
• Team Collaboration (Soft Skills)
• Evidence-Based Care Planning (Hard Skills)
• High Workload Management (Hard Skills)

Job Summary:

• Assess community member’s functional status, strengths, and limitations, including identification of issues and challenges in home environment, social support network (family and friends), 
• Caregiving responsibilities, housing status, financial security, food security, transportation, access to primary and specialized health care, level of community engagement and participation in health and wellness activities. 
• Assess client’s interests and challenges in seeking support. 
• Develop an individual, person-centered and strengths-based plan to address the service needs identified in the assessment
• Ensure the implementation of the client-approved care navigation plan by coordinating and arranging services as necessary based on the client’s functional capacity as determined in the assessment.
• Consistently evaluate the quality and effectiveness of the services provided to the client and client’s satisfaction with services.
• Providing crisis support, care coordination and individualized service navigation.
• Follow-up with clients and community partners to ensure receipt of services, maximize client utilization of services and programs, and document the outcome of referrals and client satisfaction.
• Assess clients’ needs and eligibility for volunteer peer support and work with staff to secure appropriate volunteer matches.
• Conduct regular client check-ins to provide on-going emotional and practical support, identify shifts in baseline needs and the necessity for new referrals, and assess satisfaction with services and peer support as appropriate.

Skills on Resume: 

• Assessment Skills (Hard Skills)
• Person-Centered Planning (Hard Skills)
• Care Navigation and Coordination (Hard Skills)
• Quality Evaluation (Hard Skills)
• Crisis Support and Care Coordination (Hard Skills)
• Follow-Up and Documentation (Hard Skills)
• Peer Support and Volunteer Coordination (Hard Skills)
• Client Engagement and Support (Soft Skills)

Job Summary:

• Work with the clinical care team to provide retention services to clients who have fallen out of care, who do not maintain consistent care, or who are vulnerable to being lost to follow-up
• Seek out clients by phone and in the field to establish relationships
• Conduct outreach to identify and enroll clients in psychosocial and primary care services across programs at San Francisco Community Health Center
• Attend appointments with clients when necessary, and
• Reinforce treatment goals that clients develop with medical care providers and
• Tailor health education to the client and provide support for antiretroviral initiation and consistent adherence
• Educate and support clients to be more familiar with and better access different systems of care (medical, complementary therapy, mental health, substance use, etc.)
• Provide prevention and risk reduction counseling for high-risk clients
• Participate in lost to follow up staff meetings to review out of care clients
• Participate in required HIV Care Services, inter-departmental and agency-wide meetings, trainings, and activities, which may include some evening and weekend hours
• Document and report Units of Service (UOS) and other required progress reports in a timely manner

Skills on Resume: 

• Client Relationship Management (Soft Skills)
• Outreach and Enrollment (Hard Skills)
• Appointment Coordination and Attendance (Hard Skills)
• Health Education and Counseling (Soft Skills)
• Knowledge of Care Systems (Hard Skills)
• Counseling Skills (Soft Skills)
• Documentation and Reporting (Hard Skills)
• Team Collaboration (Soft Skills)

Job Summary:

• Provide clinical support to providers at the Kempe Center (i.e. CPT, IMHOFF, etc.) and CARE Network designated providers.
• Manage clinical calls for CARE Network, CPT and IMHOFF and provide linkages, documentation, and additional support 
• Initiate the consultation episode by collecting specific information around the patient, the service being requested
• Coordinate, schedule, track all 1x only medical consults.
• For face-to-face or telehealth consultations will guide the process including ensuring all requested pre-consult materials are complete such as testing, other pertinent historical information, etc.
• Facilitate clinical services meetings (i.e. CPT, Staffings, IMHOFF).
• Coordinate coverage/payment verification and authorizations.
• Register and schedule clients as indicated, conduct appointment confirmation calls
• Assist in organizing all clinical training.
• Provide training as indicated (i.e. clinical training for healthcare providers including CARE Network providers, general training regarding clinical services for other professionals).
• Help develop a tracking mechanism for services provided to include surveys.
• Will enter the data obtained from each distinct point of contact with pediatric primary care providers into the secure database management system.
• Assist in designing and administering quality improvement programming.
• Help develop content for distribution and outreach.
• Provide general support to Kempe Center clinical team, CARE Network and Medical Director

Skills on Resume: 

• Clinical Support Skills (Hard Skills)
• Coordination and Scheduling (Hard Skills)
• Documentation and Data Entry (Hard Skills)
• Communication and Interpersonal Skills (Soft Skills)
• Quality Improvement and Program Development (Hard Skills)
• Billing and Authorization Coordination (Hard Skills)
• Training and Development (Hard Skills)
• Organizational Skills (Soft Skills)

Job Summary:

• Assist with patient screening, program enrollment, scheduling of clinic visits, procedures and follow-up.
• Identify client needs and fit with hub and spoke partner services
• Collaborate with care navigators at other spoke agencies and the Hub to coordinate transitions of care between providers/agencies.
• Achieve 60% productivity (24 hours) billable services per full FTE.
• Collaborate with pharmacies and Hub/Spoke team members in obtaining prescriptions, medication orders and refills, and communication in keeping with the scope of practice and applicable state and federal regulations
• Assist directly with care transitions, including up to and including accompanying clients to spoke agency appointments
• Complete data collection for clients, and enter the data into EHR or tracking tool.
• Monitor client progress via data tracking and participate in regular meetings with hub team members and other hub and spoke care navigators
• Compile required records and other audit/reporting materials
• Participate in care conferences and meetings with hub team members and other hub and spoke care navigators

Skills on Resume: 

• Patient Screening and Enrollment Assistance (Hard Skills)
• Scheduling Coordination (Hard Skills)
• Care Coordination and Transition Management (Hard Skills)
• Billing and Productivity Management (Hard Skills)
• Medication Management and Compliance (Hard Skills)
• Client Data Management (Hard Skills)
• Client Progress Monitoring (Hard Skills)
• Team Collaboration and Meeting Participation (Soft Skills)

Job Summary:

• Daily interaction with Cigna Partners
• Respond to dedicated phone, text and email within a reasonable time period
• Coordinate access to Primary Care Provider 24/7. 
• Provide access through an answering service or similar on-call access outside of normal business hours
• Coordinate access to telehealth appointments available with PCP, including the scheduling of appointments.
• Direct to urgent care centers, and when possible, coordinate access to same-day and after-hours appointments with urgent care centers, and the emergency room when appropriate. 
• When appropriate, coordinate with urgent care center or emergency room in the transfer of the patient.
• Coordinate prescription refills for Aligned CAC Participants.
• Coordinate with Cigna customer service agents to support customer requests for information/ Cigna services.
• Collect information to enable a better understanding of the patterns of Aligned CAC Participants.
• Guide Aligned CAC Participants when choosing specialists and enable smooth transition of care.
• Outreach to newly Aligned CAC Participants. 
• Scheduling of initial visits and providing information regarding services and support offered by Care Navigator.

Skills on Resume: 

• Customer Service Excellence (Soft Skills)
• Medical Coordination (Hard Skills)
• Emergency Response Management (Hard Skills)
• Prescription Management (Hard Skills)
• Patient Advocacy and Support (Soft Skills)
• Information Gathering and Analysis (Hard Skills)
• Appointment Scheduling and Management (Hard Skills)
• Collaboration and Communication (Soft Skills)

Job Summary:

• Outreach to Aligned CAC Participants to schedule an annual wellness exam.
• Provide education on resources and digital capabilities offered by PCP.
• Schedule follow-up visit, and ensure the patient is following recommended care instructions.
• Target the right providers for intervention
• Define what data we need from a clinical perspective to support the whole team's efforts
• Communicates findings and recommendations for corrective action and improvement opportunities to senior management and other appropriate stakeholders through dashboard reports, meetings and presentations, as necessary.
• Responsible for ad hoc reporting, and analytic tasks to help various areas of the company achieve departmental or company goals.
• Work closely with COPC's Rx Assistance Coordinator/Care Coordinators to help with miscellaneous duties to help drive best patient care
• Organizing physician referrals for patients who need to see specialists in NYC, the Hamptons, and sometimes globally 
• Managing requests for private nursing, hospice and other external care requests.
• Facilitating home imaging for patients via list of approved providers
• Entering data to eCW (electronic health record) and Salesforce (CRM)

Skills on Resume: 

• Patient Care Coordination (Hard Skills)
• Healthcare Education (Hard Skills)
• Provider Outreach and Engagement (Hard Skills)
• Data Management and Analysis (Hard Skills)
• Reporting and Presentation (Hard Skills)
• Analytical Skills (Hard Skills)
• Collaboration and Coordination (Soft Skills)
• Electronic Health Record (EHR) and CRM Management (Hard Skills)