Location: Burlington, MA
Job ID: 148192-1A
Date Posted: Sep 25, 2018
The Patient Engagement Coordinator assists the Ambulatory Care Managers (ACMs) and Transitional Care Managers (TCMs) in coordinating and tracking services for the targeted Medicare Accountable Care Organization (ACO) patient population. The Patient Engagement Coordinator communicates with hospitals, post-acute facilities, assisted living facilities and home care agencies for case information. The Patient Engagement Coordinator works with the patient registry, electronic health record, and patient tracking systems to assist with outreach, documentation of goal progress, coordination of follow-up care and community resources as needed under the direction of the ACMs and TCMs.
Essential Duties & Responsibilities including but not limited to:
1. Supports the ACM and TCM providing patient/family guidance, support, education, referrals, resources, coordination of care, and follow-up
2. Coordinates care for low risk patients through face-to-face and telephonic encounters assisting and collaborating with the care managers
3. Assists the care managers in obtaining medical record information, documenting all case information in the system, performing data entry into appropriate databases for monitoring and tracking
4. Advocates for patient and families; responds to and facilitates resolution of patient questions and concerns within scope of practice
5. Communicates plan of care, abnormal findings, changes in health status, and other pertinent information with the healthcare team
6. Documents critical patient information in EPIC and OPTUM
7. Provides necessary coaching to reduce or eliminate high-risk behaviors utilizing motivational interviewing skills
8. Produces reports (OPTUM/EPIC) and distributes reports to healthcare team as directed
9. Attends low-risk patient discharge planning/family meetings in preferred and non-preferred SNFs/acute rehabilitation hospital and provides warm hand-off to TCMs/ACMs
10. Supports ED transition population as directed to assist with care coordination
11. Utilizes Patient Ping to identify patients admitted outside the Lahey System. Collaborates with TCM/ACM to meet the care coordination needs of those patients.
Education: Licensed Practical Nurse. Associates /Bachelor?s degree in health-related field desirable.
Licensure, Certification & Registration: Active, unrestricted Practical Nursing License in MA. Certification as a health coach within one year of hiring is encouraged.
Experience: Minimum 5 years experience in health care system
Skills, Knowledge & Abilities: Strong interpersonal and customer service skills required to communicate with patients, family members, physicians and other health care providers, as well as other colleagues. Good knowledge of medical terminology. Must possess strong problem solving abilities and analytical skills to ensure patient?s needs are met. Must possess basic computer skills to input and retrieve clinical information, as well as patient registration. Utilizes critical thinking and good judgment in performance of tasks. Must possess good organizational skills and the ability to multitask and to prioritize daily assignments to ensure smooth work flow
Knowledge of Windows 2000 or XP and word processing skills are essential. Must type 55 wpm. Strong oral and written communication skills. Excel, Word, Sheets, Docs or other database experience as well as proficiency with email and Internet is required.
The Lahey Model of Care - right care, right time, right place - is exactly what patients, providers and payers need and deserve. Identifying and delivering on this convergence of interests has positioned Lahey Health for further growth. Our model ensures care is highly coordinated and locally delivered, with lower costs and exceptional quality.
Lahey Health is a robust, regional system including a teaching hospital, community hospitals, primary care providers, specialists, behavioral and home health services, skilled nursing and rehabilitation facilities, and senior care resources throughout northeastern Massachusetts and southern New Hampshire. The system has a global presence with programs in Canada, Jordan and Bermuda.