Healthcare, Community Health

Oxnard, Ventura, United States | Posted on 05/03/2017

Duties:

• Assesses client and home environment to identify physical, social, emotional and knowledge barriers to optimal client care. Identified pertinent information and communicates to care team.
• Facilitates client’s health through advocacy, support with understanding and use of benefits, assistance in scheduling appointments, development of a support system, and reinforcement of self management and organizational tools.
• Supports client well-being by using strong observation and communication skills to coordinate care between physician office, client, caregiver and community resources. Provides ongoing face-to-face or telephonic visits with clients to identify barriers to accessing care, and supporting the plan of care developed by PCP and Care Manager.
• Contributes to the development of individualized care plan by using evidence-based guidelines and clinical knowledge, for client and provider, by evaluating and conducting home visits, gathering assessment information, and identifying problems, goals and interventions.
• Assists clients and caregivers in taking an active role in health management and promotion, through coaching, education, navigation and referrals to appropriate care and community based resources.
• Comprehensive knowledge of community and public resources serving the client population. Thorough understanding of how to access/maintain and actively assists clients to secure resources.
• Reviews adherence to physician’s recommendations, assessing barriers to care, and documenting information for the care team.
• Develops cross-functional relationships with medical groups by attending appropriate meetings, working on-site, and structuring effective communication mechanisms.
• Exhibits strong interpersonal, critical thinking and analytical skills through positive communication with clients, caregivers, care team and community agencies.
• Demonstrates excellent organizational, decision-making and multi-tasking skills as demonstrated by problem solving and successful outcomes.
• Completes timely and accurate documentation in multiple computer systems to record assessment, observations and corresponding documentation, including care plans, and progress notes.
• Enhances skills and knowledge by participating in educational offerings and team case conferences and training per department guidelines.
• Utilizes department desktop procedures, workflows, job aids and training material. Identifies barriers to work processes and brings to the attention of the supervisor/manager.
• Maintains the client‘s right to privacy
• Adheres to all quality, compliance and regulatory standards to achieve desired outcomes.
• Contributes to team effort by accomplishing related results, as needed.

• AA degree, or 2+ years of college in human services field.
• Proficient in MS Office.
• Broad understanding of local community resources for seniors and disabled.
• Understanding of confidential information.
• Working knowledge of medical terminology and abbreviations.
• 2+ years of experience in community services, in a healthcare environment;
  Medicare/Medicaid experience.
• 2+ year experience with geriatrics and disabled individuals and their families, community-based experience.
• Work is primarily in the field (based out of home office), must be willing to travel in assigned locality. Bi-monthly office visits to assigned locality.

• Bachelor's Degree