Patient Care Advocate

FSL Programs•Phoenix, AZ

1d•$23 - $28•Hybrid

About The Position

Committed to the constant pursuit of excellence in improving the health status of the patient and decreasing hospital readmission rates, ensures the safe and effective transfers of patients across the care continuum, serving as the bridge between the professional staff in a care setting, (e.g. hospital), the patient and/or family and the community healthcare provider. Informs and guides both staff and patients working to ensure an effective care transition from the hospital to the patient’s home; helps teach and train patient self-management skills as well as enhancing patient-healthcare provider communication; and provides support to ACTIVATE staff, Hospital personnel and community partners in the field, and provides assistance by phone or in-person to high-risk beneficiaries by identifying social determinants of health and connecting them to community services. This position does not have direct reports.

Requirements

Bachelor’s Degree in Social Work, Human Services, Psychology or Public Health or Nurse (LPN or RN) Licensed by the Arizona Board of Nursing
Minimum of 2 years of working with patients in a primary care setting or related work experience
Valid AZ driver’s license and acceptable MVR
Valid CPR/First Aid Certification or ability to obtain within 30 days of position entry
Must be at least 21 years of age
Clear fingerprint background screening through the Department of Public Safety and comprehensive background clearance
Excellent verbal, written, reading, and listening communication skills to include communicating clearly, effectively, tactfully, and patiently to a diverse population
Strong interpersonal skills and demeanor with the ability to build rapport and garner trust with others
Accurate keyboarding skills
Strong planning, organization and time management skills in order to meet deadlines
Proficient in the use of healthcare data management systems such as CarePort, Cerner, and Apricot
Proficient in the use of a PC; in a Windows environment; in the use of the Internet; and in the use of MS Office Applications such as Outlook, Teams, and Word, and the use of SharePoint
Ability to interact with others in a professional, respectful, positive, helpful manner, promoting trust with others, and build and maintain strong, effective working relationships with internal and external customers
Ability to follow-up and follow-through with strong attention to detail
Ability to follow oral and written instructions
Ability to maintain patient confidentiality, privacy and dignity at all times
Ability to work both independently and collaborative as part of a team
Ability to travel up to 50% of the time within the Greater Metropolitan Phoenix area using personal vehicle properly insured
Ability to solve problems by applying analytical skills to include: collecting and reporting information, Identifying trends and exceptions, investigating to define problems more accurately, sorting information in order of importance, identifying relationships and linkages between components, identifying variable potential causes and effects, soliciting guidance to define criteria and assign values of importance and urgency, escalating issues of an exceptional nature
Willingness and ability to embody AllThrive 365’s core values: COMPASSION, GROWTH, RESILIENCE, OPENNESS

Nice To Haves

Healthcare experience
Knowledge of needs of older adults, the aging process, and the needs of adults with Disabilities, adults with traumatic brain injuries (or TBI) or SMI
Bilingual in English/Spanish

Responsibilities

Runs and screens daily census reports for potential patient enrollments
Meet with patient/family at hospital bedside to introduce the program and gather enrollment data
Reinforces program enrollment and patient responsibilities with the patient and caregiver
Prioritizes referrals and activities according to intensity, need, and required follow-up working to ensure outcomes are met
Serves as a Patient Care Advocate to the patient, coaching the patient and caregivers in addressing social determinants of health
Provides information and navigation to the patient and/or family for an effective care transition, improved patient self-management skills and enhanced patient-healthcare provider communication
Evaluates aspects of each patient’s condition, diagnoses, medications, and support systems to formulate an individualized plan which will lead to successful outcomes in: medication self-management, use of a dynamic patient-centered record, appropriate primary care and specialist follow-up, knowledge of red flags
Serves as a liaison between primary care providers, and community resources on behalf of patients to ensure patient-centered coordination of care
Works in the hospital and community, makes rounds in the hospital, makes home visits and follow-up phone calls
Acts as a continuing resource for the hospital personnel, patients and/or caregivers
Completes the necessary assessments and referrals by collecting data on clinical indicators
Maintains databases on ACTIVATE-enrolled population ensuring accurate and timely documentation
Ensures compliance with all AllThrive 365 policies, procedures, and practices regarding the Activate Transitional Care program, and other contract and licensure requirements laws related to patient confidentiality, release of information, and HIPAA; and applies knowledge to the work in accordance with quality standards
Uses safe work practices
Promptly reports workplace and patient safety issues to supervisor
Attends and actively participates in initial and on-going training and development programs and opportunities, weekly unit meetings all staff meetings, and demonstrates learned concepts on the job
Participates in assigned work teams, as requested and appropriate
Engages in continuous improvement efforts, as assigned, and strives to continuously improve the quality of care and self
Communicates daily and as necessary with colleagues, supervisor, leadership and medical staff
Building, cleaning, and organizing durable medical equipment
Other duties as assigned