Your Valued Contributions:
Supports patient in improving their health, wellbeing, and self-care by providing education on recommended services and preventive care. Actively engages patients to close clinical quality gaps by facilitating timely access to screenings, tests, and care appointments. Promotes proactive health management through personalized outreach and communication, ensuring patients receive the right care at the right time to improve outcomes and meet quality standards.
1. Patient Care Activities
a. Systematically works insurance gap reports; generates and monitors internal gap reports and needed services from the electronic medical record (EMR), Azara, and other software.
i. Educates patients on needed services including annual exams, recommended screenings, tests, and labs.
ii. Assists patients with scheduling of appointments to address gaps in care or needed services.
iii. Assists in requesting, obtaining, and organizing medical records and documentation necessary to close clinical quality gaps and support timely patient care interventions.
iv. Submits required documentation to insurance companies to close gaps that patient has already completed.
b. Obtains diagnosis gap reports from insurances and addresses these with the patient’s PCP. Faxes completed documentation or submits documentation online, per insurance reporting requirements, to close diagnosis gaps.
c. Assessing patient attribution and completing provider change requests on patients when needed.
d. Aids with tracking and monitoring orders for laboratory tests, radiology imaging, and specialty referrals to ensure timely follow-up, reduce organizational risk, enhance care coordination, and promote patient safety.
2. Patient Centered Medical Home:
a. Proactively supports PCMH initiatives related to care coordination.
b. Proactive member of care teams in team-based care initiatives.
3. Communication and Documentation:
a. Thorough and timely documentation of all contact or attempted contact with patients.
b. Establish and maintain positive working relationships with insurance representatives for all insurances to ensure we have the most up-to-date requirements for closing gaps in care.
c. Communicates gaps in care and needed services with care team through the EMR.
d. Systematically tracks activities to ensure patient compliance.
e. Assists with quality reporting as needed.
f. Maintains ongoing communication and positive working relationships with site management to foster collaboration, align on quality initiatives, and support coordinated efforts to close care gaps and improve patient outcomes.
g. Presents at monthly site, MSS, and/or provider meetings to educate and remind staff of documentation needed for successful gap closures.
4. To connect people in need to the right services or support, to improve health and wellbeing outcomes in a timely and appropriate way.
a. Identifying patient health and wellbeing needs.
b. Locates and connects patients with local resources that support their health goals, including referring to a Community Health Worker when social determinants of health barriers are identified.
c. Enabling and empowering individuals to seek early intervention and prevention services.
d. Supporting and assisting individuals to contact; access and engage with local services to meet their healthcare needs.
