Diabetes Clinical Outreach Coordinator
Full Time
Winter Haven, FL 33880
Posted
Job description
Title: Diabetes Clinical Outreach Coordinator
Reports to: CMO
FLSA Status: Exempt
Personnel Supervised: None
Personnel Supervised: None
POSITION SUMMARY:
Provides education and case management services to chronic care patients, which includes patients with Diabetes. The Diabetes Clinical Outreach Coordinator act as an educator, Care Coordinator, resource and advocate for all patients at CFHC. The Diabetes Clinical Outreach Coordinator will assess and develop a care plan in collaboration with the care team (Primary Care Provider, Nutritionist, Healthy living Coach, patient, and any other essential members of the clinic team) with providing health education services. The Diabetes Clinical Outreach Coordinator is responsible for developing a positive relationship with patients and assisting the patient through the process of actively working towards optimal health and glycemic control by providing support, encouragement, and education.
MINIMAL QUALIFICATIONS:
- Three (3) years of experience working with Diabetic patients.
- Bachelor's degree in health-related field or equivalent experience as a medical assistant or licensed practical nurse is preferred.
- Data entry skill required. Experience with Microsoft Word, Excel and Power Point.
- Willing and able to work well with low income individuals and residents.
- Bilingual (English/Spanish) ability (preferred).
- Experience with electronic medical records is highly desired.
- Basic medical terminology knowledge.
- Strong interpersonal skills, energetic, passionate, and innovative.
- Demonstrates ability and desire to relate to and work with people of all ages, social and ethnic backgrounds and to convey a sense of confidence and trust to all patients.
- Demonstrated ability to work independently and as a team member improving delivery of care to persons with chronic diseases.
- Demonstrates sound problem-solving skills.
- Confident to communicate and outreach to other community health care organizations and personnel.
RESPONSIBILTIES AND PERFORMANCE EXPECTATIONS include, but are not limited to, the following:
- Lead efforts in collaborative goal setting and reviewing goals.
- Patient will be informed what HgBa1c is, and HgBa1c goals.
- Conduct outreach.
- Conduct medication review/reconciliation
- Educate the patient during visits.
- Collaborate with the patient and family, set goals for diet and exercise.
- Facilitates the development and communication of policies and procedures to employees within the Diabetes Program.
- Organizes diabetic clinics and educational events, tracks diabetic patients, and maintains records for grant reporting.
- Works collaboratively with the provider, dietician, pharmacist, healthy living coach, QI, case managers, all care teams, and the Health Education Department.
- Visits villages for education functions and organizes community outreach and health fairs in schools and community settings.
- Provides nutrition and diabetes resources to patients and their families.
- Works collaboratively with the Grant Management Department to provide input regarding the needs of the program.
- Work with medical staff to develop, implement, and carry out programs in chronic disease management for patients with such problems as diabetes, coronary artery disease, COPD, and congestive heart failure.
- Work with the medical providers and pharmacy team to optimize pharmacologic therapy with a goal of lowering a1c and improving outcomes.
- Review provider schedules and individual patient charts and assist the care team in coordinating care for visits and for future healthcare needs using Care Management criteria.
- Develop and coordinate patient outreach programs.
- Provide an effective communication link between patients and medical staff.
- Maintain the strictest confidentiality and adhere to all HIPAA guidelines and regulations
- Performs all job functions according to CFHC mission and values.
- Performs outreach to patients with chronic conditions including hypertension, diabetes, and pre-diabetes.
- Connects chronic care patients to services based on recommendations of age, gender, and risk factors, to ensure that the patient is accessing what he/she needs to improve or maintain health status.
- Implements Patient-Centered Medical Home principles to manage care of patients in conjunction with the patient care team.
- Engages patients and families in developing health care strategies aimed at improving quality of life through education, empowerment, and access to appropriate healthcare, preventative services, and chronic conditions services.
- Provides evidence-based educational materials to the patient as directed by the provider or other care team members to empower the patient with self-management of their health and conditions.
- Tracks patients in population health platforms to manage patient populations, vulnerable and high-risk patient populations and patients needing follow-up and preventative care services.
- Enrolls and manages eligible patients into managed care program.
- Connects chronic care patients and patients enrolled in a managed care programs to health education and activities, behavioral health or substance abuse treatment services, and other community resources to ensure that the patient is accessing what he/she need to improve or maintain health status.
- Ensures patients with chronic conditions are screened for SDOH, makes referrals to connect patients with identified needs, and tracks data in the patients’ electronic medical record.
- Completes required and requested reports for grants, PCMH, UDS, HEDIS, payors and performance improvement objectives.
- Assists with other projects involving outreach and connecting patients to chronic care services as assigned.
- Assists in the collection of key data points to track PCMH, UDS, HEDIS and other measures to meet or exceed quality benchmarks.
- Places outreach and follow-up calls to assigned patients and tracks calls made.
- Tracks patient compliance with recommended care.
- Assist in tracking quality indicators, providing data analysis and trending to the CMO.
- Provides referral coordination and tracking to outside medical agencies. Acts as an advocate for specialty care for patients.
- Attempts to resolves all patient and provider concerns pertinent to screenings and referrals.
- Answers and returns phone calls to patients in a timely manner.
- Performs quality assurance and utilization management audits of patient charts to assure compliance with various program expectations.
- Knowledge of marketing and communications principles and presentation techniques for culturally diverse audiences.
- Knowledge of effective health promotion education principles and methods.
- Knowledge of social science assessment, intervention, and consultation principles and practices.
- Skill in organizing work activities to meet established objectives.
- Skill in communicating effectively in writing and orally to individuals and groups.
- Skill in applying interviewing and assessment techniques for culturally and socio-economically diverse populations.
- Ability to develop and present effective health promotion marketing and educational materials in a variety of settings.
- Ability to establish and maintain effective working relationships with a diverse population of community members, medical providers, businesses, schools, community-based agencies, and departmental staff.
- Ability to collect and maintain program data and confidential information.
PHYSICAL REQUIREMENTS:
- Standing for short periods of time
- Sitting for long periods of time
- Bending
- Stretching
- Walking moderate distances
- Operating keyboard equipment (computer keyboard, calculator, printer, etc.)
- Reading forms/instructions/technical information
- Following non-technical/technical directions
- Communicating with people of all ages, educational levels, cultural backgrounds in person and by telephone
- Working under moderate and tight deadlines
American with Disabilities Act (ADA) Statement: External and internal applicants, as well as position incumbents who become disabled, must be able to perform the essential job specific functions (listed within each job responsibility) either unaided or with the assistance of a reasonable accommodation to be determined by the organization on a case by case basis.
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