Essential Functions:

• Support individualized patient care plan
• Address patient risk factors and/or obstacles to care (social determinants of health)
• Facilitate engagement between PCP and patient (appointment setting, documentation)
• Maintain predetermined patient caseload
• Refer patient to and seek advice and sign off from Care Manager as appropriate
• Participation in required care coordination case conferences
• Find solutions to difficult and/or sensitive problems
• Provide inpatient tracking and coordination from ADT feed notifications
• Work as patient advocate
• Performs miscellaneous job-related duties as assigned
• Close quality gaps

Required Skills/Abilities:

• Demonstrates professionalism, confidentiality, and diplomacy and can serve a wide range of employees and patients with equity and tact
• Works collaboratively with the Care Center, patients, and the Advocare Population Health team to achieve success
• Ability to establish and maintain effective working relationships with a diverse group of patients and people at all levels of the organization
• Commitment to excellence and high standards
• Detail oriented with strong follow-up initiative
• Ability to collaborate effectively with team members
• Effective verbal and written communication skills
• Versatility, flexibility and a willingness to work within constantly changing priorities with enthusiasm
• Must be able to travel to the Home Office and care centers occasionally

Education and Experience:

• High School Diploma/GED and 3+ years of relevant healthcare experience in a similar role; or Associate degree in a health-related or science area of study and 1+ years of experience in a similar role; or Bachelor’s degree in a health-related or science area of study and a minimum of 1 year of experience in a similar role
• Work experience in one or more of the following settings: Acute Care, Ambulatory, Specialty, Physician Office, Care Management or Home Health Care
• LPN, CMA, or MA preferred