Care Management Outreach Coordinator, Per Diem

Location: Northern

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* 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 helping patients and their caregivers navigate and access community services, other resources, and adopt healthy behaviors mainly through in person home visits or community-based visits. The CMOC supports the care managers through an integrated approach to care management and community outreach. The CMOC provides social support and informal light health coaching, advocates for individuals and community health needs with government agencies or health service providers, supports telehealth visits and health screenings.
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* JOB DUTIES AND RESPONSIBILITIES:

*** Complete assigned care plan tasks as assigned by the Care Manager to address SDOH barriers and work toward meeting care plan goals.
* Develops and maintains relationships 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 in person home visits, community-based visits, and telephonic outreach.
* Screens for home safety and health concerns.
* Compliant with annual network or department competencies focusing on health coaching patients on self-management tools related to chronic illnesses and appropriate health coaching.
* Telehealth visit assistance with technology, access to SLUHN.org, MyChart access and gathers medication bottles, patient questions for review by RN Care Manager
* Assists patients and RN Care Manager with medication review during home or community visits.
* Utilizes motivational interviewing technique and scripting when outreaching the patient or caregiver.
* Attend provider and community appointments with patients as directed by Manager
* Provide referrals for services to community agencies utilizing Findhelp as appropriate.
* Maintain timely, accurate, complete, and consistent documentation appropriate to role 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.
* Participates in precepting new employees as assigned.
* Participates in peer educational presentations.
* Attends scheduled rounding and site visits and on-site meetings or education as required.
* Screens the need for referrals and determine eligibility for services, according to government and local program guidelines.
* Supports Network and department goals and objectives.
* Appropriate time management with regard to home visits and documentation.
* Contributes and maintains knowledge of current SLUHN care management programs available to patients and families.
* Completes Community Health Worker course within 1 year of hire date.
* Maintains confidentiality of all materials handled according to Network/ Entity policies.
* Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes, and practices.
* Complies with Network and departmental policies regarding attendance and dress code.
* Other related duties as assigned.
* Must have a valid driver's license and reliable…