Care Specialist - Enhanced Care Management

About the role

The Care Specialist - ECM coordinates care for high-complexity patients, primarily working in the field to provide chronic care coordination and support. This role involves direct outreach to patients through phone calls, home visits, and community interactions.

Responsibilities

• Assess patient needs
• Help set health goals
• Ensure patients receive appropriate care and resources
• Increase access to preventative care
• Reduce emergency room visits
• Enhance self-management

Requirements

• At least 2 years of relevant work experience as a Community Health Worker, Peer Support Specialist, Medical Assistant, or in a similar role.
• High school diploma or GED required.
• Valid driver’s license and auto liability insurance.
• Reliable transportation and the ability to travel within assigned territory or as needed.
• Experience in care coordination for individuals with chronic conditions, behavioral health conditions, or with patients experiencing housing insecurities including homelessness.
• Strong interpersonal and motivational interviewing skills to build trust and rapport with patients.
• Familiarity with trauma-informed care, care coordination, and patient education.
• Proficiency in the use of electronic medical records (EMR) systems and basic computer skills.
• Technologically savvy and able to manage documentation and data entry effectively.
• Ability to work independently in a field-based environment and as part of a team.
• Multi-lingual capabilities preferred but not required.
• Prior home care or Enhanced Care Management experience a plus.
• Community Health Worker certification is a plus.

Key Behaviors

• Adaptability: Ability to work in dynamic, unstructured environments, pivoting quickly to meet the needs of patients and the organization.
• Critical Thinking & Problem Solving: Demonstrates strong problem-solving skills when assessing patient needs and determining the best course of action.
• Motivational Interviewing & Empathy: Uses motivational interviewing techniques to build rapport, set health goals, and empower patients to take charge of their care.
• Relationship Building: Skilled in establishing trust and fostering strong relationships with patients, families, and team members.
• Self-Starter: Takes initiative to perform outreach, complete assessments, and follow through with care coordination independently.
• Organizational Skills: Excellent at managing time, tasks, and schedules, ensuring that all patient needs are addressed in a timely manner.
• Resilience: Demonstrates resilience in challenging situations and remains focused on the goal of improving patient outcomes despite setbacks.
• Cultural Competence: Demonstrates sensitivity to and understanding of diverse cultural backgrounds, ensuring that care is provided in a culturally inclusive manner.
• Commitment to Quality Care: Shows passion for delivering high-quality care and support to patients, ensuring their well-being and satisfaction.

Competencies

• Care Coordination: Ability to assess patient needs, coordinate care with interdisciplinary teams, and ensure patients are receiving the appropriate services.
• Patient Advocacy: Supports patients by navigating healthcare systems, advocating for needed resources, and ensuring timely access to care.
• Health Education & Communication: Educates patients about their health conditions, treatments, and the healthcare system in a clear and empathetic manner.
• Data Management & Reporting: Proficient in documenting patient interactions and maintaining accurate, up-to-date records in EMR systems.
• Patient Outreach & Engagement: Proactively reaches out to patients through multiple communication channels, including phone, in-person visits, and community outreach.
• Goal Setting & Self-Management: Works with patients to develop self-care plans, emphasizing shared decision-making and increasing the patient’s ability to manage their own health.
• Collaboration & Teamwork: Works effectively as part of an interdisciplinary care team to achieve organizational goals and improve patient outcomes.
• Crisis Management & Flexibility: Demonstrates flexibility and adaptability in managing unforeseen challenges, providing support where it is needed most.
• Technical Proficiency: Skilled in using healthcare software applications and systems for accurate data entry and patient management.

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