Department: Care Management Services FTE: 1.00 Full Time Shift: Days
Position Summary: Perform activities to coordinate and integrate health services for patients without a primary care medical home at UNM Hospital. Meet with non-emergent emergency department and inpatients to assess whether patient has a primary care medical home, need for financial assistance and other social needs that affect patient ability to access primary or specialty healthcare outside emergency services. Provide education about possible primary care medical homes, assist with scheduling follow up appointments, and arranging transportation /support services as needed. The community referral coordinator will also refer patients to Patient Financial services or other agencies as needed for financial resources to assist with obtaining healthcare in the community. Ensure adherence to Hospitals and departmental policies and procedures. Patient care assignment may include neonate, pediatric, adolescent, adult and geriatric age groups.
Detailed responsibilities: * RESOURCE COORDINATION- Assist the patient in obtaining access and coordinate necessary appointments and other services to include assistance in obtaining financial and medical benefits/entitlements, assist in obtaining and maintaining stable housing; coordinate transportation as necessary to assist patient with navigating health system * COLLABORATION- Collaborate with medical providers, multidisciplinary team members and community resource providers to assist patient in navigating health system * NAVIGATION/PATIENT ADVOCACY- Work to eliminate barriers at access culturally competent medical services for all patients: assess patients to access community resources, primary care medical homes, financial assistance programs and other services as necessary * SUPPORT SERVICES - Encourage the development and eventual succession of natural supports in the workplace, school, family, and community environments * ASSESSMENT - Work with the individual/family to identify personal strengths, needs and barriers to attaining self-identified goals; conduct ongoing assessments to determine if the services accessed are meeting or have adequately met the individualâs needs * TRACKING â Coordinate and monitor the use of services as appropriate; conduct post discharge follow-up as appropriate * DOCUMENTATION â Document all patient encounters and those made on behalf of patients * STATISTICS - Maintain and report applicable statistics regarding programs and client services * DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops * PATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocols * PATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes * PATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk * PATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner * PATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may "not seem right"
Experience: Essential: 1 year directly related experience
Nonessential: Bilingual English/Keres, Tewa, Tiwa, Towa, Zuni, or Navajo
Credentials: Essential: * CPR for Healthcare/BLS Prov or Prof Rescuers w/in 30 days * Licensed BSW (LBSW) in State of New Mexico
Physical Conditions: Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
Working conditions: Essential: * No or min hazard, physical risk, office environment