• Work collaboratively with multiple teams to implement care plans for adult primary care patients, utilizing tools and accessing resources available to the patient in their home, from their medical providers or in the community 
• Proactively monitor population/case load to meet treatment/care plan guidelines  
• Communicate urgent patient concerns or issues to PCP or provider office staff.

Requirements

• For MAs, Certification from an accredited Medical Assistant training program.
• LPNs, RNs, Pharmacy Techs also considered.
• Any second language a plus, especially Spanish
• Successful completion of a state and federal background check
• Willing to work flexible hours depending on client location.

Primary Responsibilities:  

• Perform proactive outreach to enroll potentially eligible patients; most communication is over the phone 
• Conduct initial visits, including detailed history and education about the nature of the targeted conditions and the goals and expectations of treatment  
• Use effective engagement strategies to build a trusting relationship with patients so that they can actively participate in managing their healthcare
• Use a variety of educational materials, self-management support techniques, and community resources to engage patients, increase their motivation to change, and support patients in establishing healthy lifestyle goals and implementing treatment plans to meet those goals according to established care plans.
• Use and maintain an Electronic Health Record and/or registry for ongoing documentation and active follow-up for enrolled patients  
• Clearly and effectively communicate with the patient, primary care physician and consulting providers about the patient’s progress
• Systematically review the caseload with the consulting physicians and prioritizing according to established protocols.
• Coordinate services (e.g., primary care physician visits, preventive care schedules, and specialty referrals) and transitions between care settings  

Desired Skills, Attitudes, and Experience

• Scrupulous adherence to HIPAA privacy and security policies
• Proficiency with or able to quickly acquire skill with Microsoft Office Suite and other web-based tools and systems.
• Detail oriented, well organized, with time-management and project management skills
• Comfort talking to patients with both medical and mental health conditions
• Strong written and oral communication skills
• Comfortable with a patient-centered approach that allows the patient’s desires around behavioral change to inform the plan of care 
• Clinical skills or aptitude in problem-solving and behavioral change strategies, including motivational interviewing and behavioral activation 
• Ability to serve as a critical liaison to facilitate connections between people in a collaborative role 
• Ability to provide accurate feedback about medical and behavioral health conditions without judgment or discomfort 
• Ability and willingness to work in a time-limited, structured, and solution-focused environment 
• Ability and willingness to function independently and proactively in an environment with multiple team members while fostering and maintaining a team environment 
• Flexibility to adapt to unforeseen needs or circumstances 
• Clear and effective communication of professional needs and willingness to accept support and feedback 

What does the right hire look like and embody? 

• Someone with a high level of kindness and compassion, showing empathy and the ability to meet patients where they are 
• Great communication skills, ownership and advocacy
• Humility, curiosity, discipline, and creativity  
• Able to establish relationships and trust equally with patients, PCPs and other providers 
• Friendly, assertive, outgoing, organized, proactive 
• Ability to learn quickly and readily ask for assistance.

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