Collaborate with health plans and utilize internal reporting capabilities to identify patients who have open care opportunities. Task orders to provider teams for needed services.
Contact and schedule appointments for patients with open care opportunities.
Collaborate with health plans, hospitals, and utilize internal reporting capabilities to identify patients who have a recent hospitalization or emergency department visit.
Contact patients with a recent hospitalization or emergency department visit to schedule a follow-up appointment.
Data collection and reporting on patients with a recent hospitalization or emergency department visit.
Collaborate with the patient-centered medical home inter-disciplinary team.
Actively participate with the care team, supporting and engaging the patient in treatment, clarifying/explaining provider team instructions when needed. Provide instruction for health maintenance and disease prevention.
Provide patient follow up especially for patients who miss important appointments.
Conduct interviews with patients to identify and address non-medical barriers impacting the patient's health and ability to comply with the recommended care plan.
Appropriately refers patient(s) to services.
Document patient encounters in the patient chart in the Electronic Health Record.
Maintain a current list of community agencies and resources to provide to patients and provider teams.
Assist provider teams in completing required documentation of care to ensure opportunities are captured for reporting.
Participate in the Quality Program through incident reporting and identifying opportunities for improvement.
Participate in the Compliance Program through fraud, waste, and abuse prevention, detection, and reporting; and protecting patient confidentiality under HIPAA.
Participate in the Infection Control Program through following hand washing and Blood Borne Pathogen safety and exposure protocols.
Other duties as assigned.

Chronic Disease Specialist

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