Patient Health Advocate- VBC

Benefits

• Subsidized personal healthcare coverage
  :
  Medical, Dental & Vision, plus Wellness programs
• Paid Time Off
  :
  Accrual of 3 weeks’ Vacation (PTO)
• Professional development
  : CEU and tuition reimbursement

• Works under the guidance of practice physicians and/or a nurse care manager.
• Partners closely with physicians and practice office staff to build a positive, collaborative relationship focused on working together to improve care for patients, support clinical and operational goals, and improves Somatus’ primary representative in the practice.
• Supports the preparation and management of the regular integrated, interdisciplinary care team meetings each month.
• Serve as primary contact for provider practice regarding patient needs and care coordination.
• Follow-up with health management plans and goals in coordination with the RNCM.
• Collaborates with the provider practice to build and fine-tune workflows to support operational goals with the RNCM and care team.
• Educate the provider practice about the Somatus program, reinforcing collaborative workflows.
• Function as an advocate for the patient and support the patients throughout their journeys.
• Conduct patient outreach (i.e., telephonic and in-person) to introduce and align patients to the Somatus program, encourage enrollment, and engage patients.
• Conduct outreach to members currently or recently in the inpatient setting to engage in the Somatus program and/or connect with a Transitions of Care RN to complete an assessment.
• Assist patients during periods of transitions of care tofacilitateeffective transitions and minimize avoidable readmissions.
• Assist members in scheduling appointments for follow-up post-discharge from the inpatient setting with their provider.
• Schedule members for initial and subsequent Somatus assessments with the RNCM
• Use the care coordination platform to document all activities in collaboration with physician practices.
• Engages with patients who need assistance with self-care needs, such as:
• Address language and cultural barriers to care management and self-care.
• Coach and guide the patient to meet both personal and clinical goals.
• Schedules provider appointments on behalf of their patients.
• Accompanies patients to their appointments when needed.
• Reminds patients of their upcoming appointments.
• Helps patients access community and government-based services and resources.
• Helps to reinforce education provided to the patient and/or caregiver about symptom response plans.
• Arranges transportation.
• Facilitates closing gaps in care by reinforcing education to patients about preventive monitoring and collaborating with physician practices to schedule / complete diagnostic testing.
• Assists patients with access to educational videos.
• Support NP and RNCM care team members by facilitating in-home telehealth visits with patients.
• Utilize motivational interviewing techniques to encourage patients to make behavioral changes.

• High school diploma or equivalent required.
• 1+ years of experience in case management or care management, preferably coordinating care across multiple settings.
• 2+ years healthcare related experience.
• Experience working with Medicare, Medicaid,and/or Special Needs populations.
• Experience working in a physician office.

• Medical Assistant, Licensed Practical Nurse, Patient Care Technician, Engagement Specialist, Community Health Worker experience, or exposure to Renal patients.
• Bilingual in either Spanish, Cantonese, or Mandarin, with the ability to converse fluently in a clinical setting using clinical terms.

• Demonstrated success in working as part of a multi-disciplinary team, including communicating and working with Physicians and Registered Nurses.
• Effective written and verbal communication skills that demonstrate respect and cultural awareness during interactions with patients and clients.
• Computer proficiency utilizing MS Office (Word, Excel, PowerPoint and Outlook), and telecom devices including the ability to type and talk at the same time while navigating multiple applications.
• Ability to obtain valid BLS certification from a licensed American Heart Association or…