Community Outreach/Patient Wellness Coordinator  (Full Time)
Department: Administration

GENERAL STATEMENT OF DUTIES:

In partnership with CMEP providers, the CO/PWC works collaboratively with CMEP providers, community agencies and healthcare facilities, and patients/families to identify and match patients with available resources to reduce risk and improve health. Makes recommendations to CMEP providers and administration on needed resources and the most effective/efficient use of available resources. Coordinates care across multiple settings both inpatient and outpatient and helps patient/families understand and utilize health care options.

ESSENTIAL FUNCTIONS:

• Identifies targeted populations and risk stratifies all patients to prioritize needs and direct interventions.
• Helps providers work collaboratively with patients to implement the patients individualized plan of care and assists patients in implementing the plan, resolving issues with the patient/family, healthcare team, and payor, as needed.
• Develops and improves processes to ensure new patients are matched with a correct provider and clinic, receive a welcome packet, and are correctly scheduled for initial and ongoing services.
• Serves as the CMEP representative on community-wide healthcare improvement teams, identifying trends and challenges and providing input on program development and evaluation.
• Facilitates the coordination of outpatient services including diagnostic tests and treatments, i.e. visits, testing, procedures, referrals, etc. for patients identified at high-risk. Addresses/resolves system problems impeding diagnostic or treatment progress with the ambulatory population by proactively identifying and resolving delays and obstacles.
• Promotes and facilitates the use of CMEPs sliding fee schedule program.
• If a patient is seen in the emergency department or admitted, communicates and collaborates with hospital case management to implement the discharge plan and coordinate a safe transition to the next level of care. Works in collaboration with physicians/providers, patients, and their families to ensure safe and efficient transitions of care. Identifies reason for ED/urgent care visits and makes recommendations to CMEP providers and administration on how to reduce need for future visits.
• Recommends referral of appropriate cases to other members of the care team for direct intervention (social work, registered dietician, diabetic educator, pharmacist, etc.).
• Collects data for specific performance and/or outcome indicators as determined by department and administration. Uses data to drive decisions and plan/implement performance improvement strategies for assigned patients, including fiscal, clinical and patient satisfaction data.
• Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues, involving manager or director as necessary.
• Reviews current literature regarding effective engagement and communication strategies, case management strategies, and behavior change strategies and leads the organization in adopting into clinical practice.
• Uses quality screens in electronic health record or other information technology solutions to identify potential issues, ie. care gaps, readmissions.
• Works with leadership to continuously evaluate process, identify problems, and propose process improvement strategies.

QUALIFICATIONS

• A Bachelors degree preferably in health or health related field.
• Public Health Experience a plus.
• Perspective and knowledge regarding the broad factors affecting health of individuals and communities, and how evidence-based interventions can improve health outcomes.
• Excellent oral and written communication
• Proficient in Microsoft Office
• Ability to build and maintain positive relationships

CMU is an AA/EO institution, providing equal opportunity to all persons, including minorities, females, veterans, and individuals with disabilities.

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