Community Wellness Coach: MPC-MHW - Silverlakes Practice

Summary:

Works collaboratively with physicians, staff, and other health care professionals to provide care coordination across the health continuum for all assigned patients ensuring that safety, best practice, and high quality standards of care are maintained. Serves as a mentor, educator, and advocate for personal health and wellness.



Detailed responsibilities:

• Interviews and assesses patients and/or family, caregivers, and/or legal representatives. Provides outreach to patients and families to ensure care coordination. Determines, prioritizes, provides and/or arranges for needed internal and external services. Obtains medical authorizations and scheduling primary care, specialist care, lab, and diagnostic testing appointments.


• Delivers general and specialized education on preventive and chronic care conditions measures, including weight and stress management, risk prevention and reduction, and living with specific health conditions. Responsible for regulatory compliance of Healthcare Effectiveness Data and Information Set (HEDIS) measures which are monitored and reviewed quarterly to ensure care gap metrics are achieved. Work with physicians to reduce emergency room utilization for avoidable visits through outreach and providing alternative resources.


• To independently analyze processes, high- risk patient information, identify problems and trends, and develop effective solutions and strategies. Facilitates care plans, provide updates to the team, and documents efforts. Uses varies forms of communication methods including but not limited to face-to face, telehealth, email, and mail. Works closely with physicians and the multidisciplinary care management teams.


• Provides assessment and coaching to individuals to help them develop and achieve wellness goals, including personal empowerment, lifestyle changes, and behavior modification. Assesses for Social Determinants of Health and provides community resources to leverage social barriers.


• May consult and/or train new staff, students, and interns. May serves as backup for the Medical Assistant in performing basic medical care and exams.


• Generate/analyze patient reports that are reviewed by senior at patient re-cap meetings along with key business stakeholders (Physicians, Pharmacists, and Nurses).


• Uploads and tracks patient records in Avality to ensure patient population health continuum is compliant based on HEDIS measurements.


• Adheres to CMS compliance regarding Medicaid/Medicare regulations. Ensures regulatory compliance.


• Assist with the identification, determination and need for systems, process workflows, equipment and supplies, such as: Remote Patient Monitoring Devices (BP machine) and Colorectal Cancer Screening Kits. Monitors usage and oversees proper working order of equipment and ensures adequate supplies.


• Assist patient in the comprehension of complex instructions and facilities conflict resolution. Demonstrates strong organizational skills, priority setting skills and has the ability to multi-task various competing tasks. Must be able to learn and apply large amount of technical and procedural information. Must be able to communicate effectively verbally and in writing.

Competencies and skills:Essential:

• STANDARDS OF BEHAVIOR: Acts in a manner that supports the standards of communication, respect, privacy, and teamwork by demonstrating a commitment to professional and ethical conduct.


• CUSTOMER SERVICE: Demonstrates commitment to service excellence by promptly addressing internal/external customer issues/requests, resolving concerns while maintaining a professional image and behavior to build and enhance the patient/family/customer experience.


• ACCOUNTABILITY: Accepts ownership of job roles and specific assignments/goals; works independently, takes responsibility for own actions; admits mistakes and judgment errors; and accepts constructive feedback. Connects personal work results to the accomplishment of team and organizational goals.


• RESPONDING TO CHANGE: Accepts change and adapts in a positive and productive manner; handles unexpected situations and changes in direction calmly and with confidence. Views new assignments and job responsibilities as an opportunity for growth.


• DOCUMENTING: Provides written/electronic record of details of patient care as appropriate to position, certification and skills.


• ANALYSIS AND DECISION MAKING: Uses decision making processes and tools to analyze situations and make effective decisions.


• EFFECTIVE COMMUNICATION: Communicates effectively with various audiences using the most appropriate method for the situation.


• PROBLEM SOLVING: Ability to identify, analyze and effectively solve problems.

Education:Essential:

• Accredited Program

Education specialization:Essential:

• Medical Assistant

Credentials:Essential:

• BLS Certification

Education equivalent experience:Essential:

• or Emergency Medical Technician (EMT) program.

Other information:

Complexity of Work: Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Excellent communication and presentation skills effective in working with all levels of clinicians (physicians, mid and senior levels management, Nurses, Allied, office staff, and internal/external customers. Self-starting, meticulous, and forward thinking with demonstrated case management and organizational skills. Illustrated knowledge of both healthcare operations as well as the health insurance/health plans industry and Epic expertise. Must be able to work in a stressful work environment and take appropriate action. Knowledgeable in Excel, Word, and PowerPoint. Must be able to work independently with minimal supervision.



Required Work Experience: Graduate of an accredited Medical Assistant/ EMT program with one (1) year of experience.



•• New Hires have 6 months to obtain their BLS Certification.



Working conditions:Essential:

• Keyboard Entry 60.00%


• Kneeling 40.00%


• Repetitive Movement Hand/Arm 60.00%


• Sitting 60.00%


• Standing 60.00%


• Walking 60.00%


• Audible Speech 60.00%


• Hearing Acuity 60.00%


• Depth Perception 60.00%


• Distinguish Color 60.00%


• Seeing - Far 60.00%


• Seeing - Near 60.00%


• Bio hazardous Waste 40.00%


• Biological Hazards - Respiratory 40.00%


• Biological Hazards - Skin or Ingestion 40.00%


• Blood and/or Bodily Fluids 40.00%


• Communicable Diseases and/or Pathogens 40.00%


• Computer Monitor 60.00%

Organizational Profile:

Memorial Primary Care (formerly known as South Broward Community Health Services) centers are an integral part of Memorial Healthcare System, dedicated to providing high-quality, cost-effective, patient-centered primary care. We have multiplw locations throughout south Broward County, and our highly skilled team of healthcare professionals works to meet each patient’s healthcare needs in a friendly and culturally sensitive environment.



Located in Hollywood, West Hollywood and Dania Beach, the centers offer a variety of vital programs which include disease management and pediatric services, as well as Mobile Health Centers for both children and adults.



In addition, we have Memorial Outpatient Center in Hallandale offering high-quality medical and health-related services such as mammography, bone density testing, EKGs, CT scans, Ultrasound, nuclear medicine, an adult day care center and a senior resource center.



Disclaimer: This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification.