Care Management Outreach Coordinator - Per Diem

St. Luke’s University Health Network•Allentown, PA

About The Position

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. Must have a passion to work with patients who frequently over utilize the emergency room or require coordination of resources and Pathways to Transitional Healing (PaTH) patients. Opportunity to work on special projects. The Care Management Outreach Coordinator (CMOC) will be responsible for assisting patients and their caregivers navigate and access community services, other resources, and adopt healthy behaviors. The CMOC supports providers, and the care managers through an integrated approach to care management and community outreach. The CMOC provides social support and informal counseling, advocates for individuals and community health needs with government agencies or health service providers, supports telehealth visits and performs home visits and health screenings.

Requirements

High School Graduate/GED with 3 years of patient care or community resource experience required.

Nice To Haves

Associates Degree with 2-year patient care or community resource experience preferred.
Community Health Certificate preferred - Required to obtain within one year

Responsibilities

Coordinates care with patients, providers, and care plan to identify barriers to meeting care plan goals by actively participating in care team huddles and care coordination meetings.
Develops and maintains relationship 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 telephonic and community outreach
Perform home safety evaluations and health screenings.
Assist patient in scheduling appointments and diagnostics.
Performs appropriate health coaching related to chronic illness and compliance.
Telehealth visit assistance with technology, gathers self-monitoring vital signs, and preparing medications or medication list for review with the provider.
Utilizes motivational interviewing technique when outreaching the patient or caregiver.
Attend provider and community appointments with patients as needed.
Provide referrals for services to community agencies as appropriate.
Maintain accurate, complete, and consistent documentation 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.
Maintain assigned competencies (Athena Forum, CHW webinars, journal reviews and self-study)
Participates in peer educational presentations.
Attending scheduled rounding and site visits.
Asses the need for referrals and determine eligibility for services, according to government and local program guidelines.