Allegheny Health Network
Job Description :
In conjunction with the Practice Team, provides care planning, coordination and follow-up for patients at risk for poor outcomes or experiencing poor coordination of services.
- Completes a structured assessment of medical, biopsychosocial support and self-management support needs. (20%)
- Coordinates with and acts as an advocate/liaison/contact to hospital, long-term care, specialty services, home health services, patient family, cultural and community resources for care managed patients. (20%)
- Accurately maintains appropriate documentation on care coordination to promote Practice Team awareness and ensure patient safety and follow through on care plan. (20%)
- Provides registration and billing functions; assisting patients in problem solving potential issues related to the health care system, financial and psychological barriers (10%)
- Collaborates with primary care to establish and update a shared care plan; providing support for improving health behaviors and self-management skills – goal setting, action planning, problem solving. (20%)
- Provides clinical workflow oversight (10%).
- Performs other duties as assigned or required.
- Graduate of a Medical Assistant or LPN Program. 5 years MA experience required.
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