Community Care Guide Remote

Job Description

Provides operational support and transition duties, as assigned, for identified highest risk complex patients.

Provides operational support and transition duties, as assigned, for identified highest risk complex patients. Provides extraordinary care. Works collaboratively with the care management team, patients, family caregivers, significant others, healthcare providers, payers, community-based providers, and other involved parties to provide effective, efficient, and patient-centered services.

Responsible for referral management of cases, care management pre-screening, patient scheduling, patient consultation, transition management, and other duties as assigned, and in accordance with Intermountain Health's policies, procedures, guidelines, and professional licensure, to facilitate effective and efficient operations of the team.

• Application Requirements:
  Please upload a current resume that includes your work history and relevant licenses or certifications.
• Benefits Eligible:
  Yes
• FTE:
  Full time
• Shift: Days, Fully remote, required in-person meetings.

• Understands, practices, and promotes the philosophy and guiding principles of the department.
• Demonstrate knowledge of HIPAA regulations and maintain the confidentiality of patient information to be compliant with internal policies and procedures.
• Referral Management:
  Screen, Monitors pending and prioritized referrals. Maintains a record of the average daily caseload and workload.
• Patient Consultation:
  Promptly contacts new patients by phone to introduce them to the program, obtain verbal consent to participate, and schedules the initial assessment/evaluation.
• Interventions:
  Responsible for patient follow-up calls, as assigned by the (care team, to re-enforce education, self-management, and other care planning actions needed. Collaborates, educates, communicates, and networks with healthcare providers across the continuum to ensure the patient’s care planning needs are met.
• Intervention:
  Advocates on behalf of the patient, communicating and collaborating with healthcare providers, payers, physicians, and community-based services, where appropriate, to assist in establish an appropriate and integrated care plan for each patient. Promotes mental health integration by collaboration with mental health/behavioral health providers.
• Responsible for designated transition management duties to ensure an effective transition of care from one healthcare setting to another. Actively participates in system and regional process improvement initiatives to improve transitions of care.
• Establishes and maintains current community-based services and provider resource lists.
• Promptly and accurately performs duties, as assigned, to facilitate effective and efficient day-to-day operations and communication. Promptly escalates concerns to appropriate chain of command.
• Effectively and efficiently lead interdisciplinary care conferences and huddles, using collaborative practice models that promote interdisciplinary care planning and teamwork.
• Clerical/Support:
  Completes timely and accurate documentation in the medical record using knowledge of documentation standards for the department to facilitate communication with team members. Documentation is done in compliance with all clinical guidelines and billing/reimbursement standards. Organizes and prioritizes daily work by assessing new, current, and discharging patient needs in area(s) of responsibility.
• Ensure that productivity standards and expectations are met.
• Works with other team members and leadership to develop standard work and best practices
• The following duties may not be performed in all areas:
• Clinical Support:
  Prioritizes (triage) patient needs identified through phone, electronic, in accordance with established guidelines, standing orders, and protocols. Reports significant changes in patient condition or other patient information to the care team. Following provider instructions, demonstrates accurate, timely, and efficient follow through with pharmacy refills, scheduling out of clinic procedures, obtaining, reporting, and tracking of lab results, leaving phone messages, and distributing faxes.
  
  Maintains inventory of supplies. Orders and restocks as needed to ensure availability for patient care.

• Three years of experience in patient care, care management, transition/discharge planning, medical assistance, healthcare coaching, or patient care coordination - and - Certification, Associate Degree, or Bachelor's degree in a healthcare field.
• Excellent interpersonal and communication skills.
• Ability to adapt quickly as needs arise.
• Knowledge of available health resources.

• Bachelor's degree from an accredited institution.
• Discharge/transition planning, healthcare coach, health advocate, or medical assistant experience
• Lifting, twisting, standing, seeing, manual dexterity, speaking, sitting.

Nevada Central Office

Las Vegas

Nevada