The Population Health Program at CAREMOUNT MEDICAL enables patients to be treated in an environment combining an expert medical team with individual attention and compassionate care. The Population Health Program empowers patients to actively participate in improving their own healthcare through personalized care that targets each patient's specific healthcare issues and needs. The Care Coordination Assistant seeks creative solutions to patient barriers. Some patients utilize commonly used services, but others have unique needs that require initiative and creative thinking to locate the appropriate resource. The Care Coordination Assistant works closely with the clinical team, both at the point of care and the Population Health team in a supportive role to ensure highly vulnerable patients' needs are met to improve quality outcomes. The Care Coordination Assistant is an integral part of CAREMOUNT MEDICAL Population Health care team and our approach to delivery of patient-centered, compassionate medical care, complementing the necessary professional services to patients.
Essential Duties and Responsibilities (including but not limited to the following):
The Care Coordination Assistant is an integral member of the direct delivery care team, and serves as a gateway to information and support. The Care Coordination Assistant performs ongoing review of patients identified as having quality care gaps, that impact their overall health status and performs direct outreach and education. The Care Coordination Assistant utilizes tools and documents that support a guided care process, collaborating with patients/families/Physicians and other members of the care team toward an effective plan of care during the review of the quality care gaps, including: a) Assess patient and family's unmet health and social needs b) Provide effective communications to improve health literacy c) Review the care plan based on mutual goals with patient, family and provider's emergency plan, medical summary and ongoing action plan, as appropriate. Monitor patient's adherence to plan of care and progress toward goals in timely fashion, facilitate changes as needed. d) Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists. * Ensure effective tracking of test results, medication management and adherence to follow-up appointments. * Attend and actively participate in care coordinator related training and meeting activities. * Perform regular visits to provide patient and family support and education.
Qualifications and Education: * 3-5 years' experience in clinical or community health settings, preferred * Experience with navigation of local medical and social support systems, beneficial * Previous experience with Electronic Medical Records and Microsoft Excel, preferred.
Knowledge, Skills and Abilities: * Knowledge of community health services and willingness to develop and foster relationships with community resources of direct value to CareMount Medical patients and care team. * Strong organizational skills and demonstrated the ability to maintain accurate notes and records. * Strong interpersonal skills and an understanding and commitment to delivery of patient centered medical care with a team-based approach * Ability to work independently, exercise creativity, is attentive to detail. * Ability to manage multiple and simultaneous responsibilities and to priorities scheduling of work autonomously
All qualified applicants will receive consideration for employment without regard to race, ethnicity, color, religion, sex, gender identity, sexual orientation, national origin, disability, or protected veteran status. CareMount is an EO employer - M/F/Veteran/Disability
CareMount Medical is the largest, independent multi-specialty medical group in New York State. CareMount Medical provides the highest quality medical care in over 40 different locations throughout Westchester, Putnam, Dutchess, Columbia and Ulster counties. We provide medical care to over 500,000 patients in 43 different locations.Founded in 1946, CareMount Medical has grown to 560 physicians representing 43 different medical specialties with major campuses in:Mount KiscoCarmelKatonahKingstonFishkillJefferson ValleyPoughkeepsieRhinebeck