Key Responsibilities:
- Collaborate with care teams to identify, track, and close clinical care gaps (e.g., immunizations, screenings, chronic disease management) by utilizing health IT systems and registries.
- Monitor patient progress toward closing care gaps and ensure timely follow-up for all open gaps.
- Develop and implement creative strategies to ensure patients attend medical appointments and adhere to prescribed care plans.
- Measure and report on care gap closure efforts, including percentage of patients with closed care gaps, using HRSA standards and Medicaid guidelines.
- Identify and address social determinants that impact patients' ability to access care, including transportation, housing, food insecurity, and mental health.
- Refer patients to appropriate community resources and support services.
- Develop partnerships with local organizations to expand the resources available to patients.
- Create and implement innovative strategies to increase patient attendance at scheduled medical appointments, including reminder systems, transportation solutions, and extended hours.
- Coordinate with medical assistants (MAs) and LPNs to ensure patient engagement through appointment reminders, follow-up calls, and assistance with scheduling.
- Ensure timely referrals to appropriate specialists, behavioral health providers, and community services.
- Track and follow up on referral completion and report on referral effectiveness and patient outcomes.
- Work closely with interdisciplinary care teams (physicians, nurses, medical assistants, LPNs, case managers) to coordinate care and ensure that patients are receiving the right services at the right time.
- Provide case management for high-risk patients, including those with chronic conditions and frequent ER visits.
- Actively participate in continuous quality improvement initiatives and provide input on care process improvement.
- Use data to evaluate program effectiveness and make recommendations for improvement in care delivery.
- Provide training to clinical staff, including LPNs and MAs, on best practices for patient engagement, care coordination, and addressing SDOH.
- Educate patients on the importance of preventive care, self-management, and adherence to care plans.
- Ensure all care coordination activities and referrals are documented accurately in the electronic health record (EHR).
- Prepare regular reports on population health initiatives, including data on care gap closure, patient outcomes, and quality metrics.
- Ensure compliance with HRSA, PCMH, and Medicaid documentation standards.
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