DUTIES: - Provide pre-visit review of patients (Pts) charts, communicate with provider GAP in services, coordinate all preventive care services and review charts for all quality improvement. Track Pts' progress through health education curriculum, reinforce and coach. Provide critical feedback to members of the health care team through HER notes and messaging. Participate in multidisciplinary care conference meetings and phone communications. As needed, provide screening for social determinants and make appropriate referrals. Conduct social service and benefits assessment and follow-up. - Coordinate on-going navigation, logistical support for medical/mental health appointments, transportation, durable medical equipment (DME), CHHA (Certified Home Health Agency), social services and community-based organizations. Identify and solve barriers to achieve Pt's goals. When appropriate, engages community agencies and programs to resolve issues. Identify information to the primary Care Physician (PCP), specialist and members of the Pts care team. - Link Pts back to all established services including PCP, specialists, Health Home, Home and Community Based Service (HCBC), Managed Long-Term Care (MLCT), Managed Care Organization (MCO), etc. Collaborates with nursing and physician staff on an ongoing basis as to pts's condition, follow up needs and other relevant information that may contribute to the transition plan. Communicate with Pts's physician(s), long term care providers as required to improve member adherence and continuity of care. - Assists with all quality improvement metrics (PCMH, QIP, MU, MIPS etc.); work collaboratively with Inpatient/ED Case Managers and Social Worker to facilitate discharge plans; assist with PCP/specialists appointments; documents and maintains patient-specific records/data as assigned. All other assigned work as needed. (DUTIES AND RESPONSIBILITIES ARE NOT LIMITED TO THE ABOVE POSITION DESCRIPTION) QUALIFICATIONS: Working towards a bachelor's degree is preferred, but not necessary. One to two years experience. Bilingual preferred (Haitian, Creole, Spanish). Excellent verbal and written communication skills. Additional Info: *Please include the five digit line number and job title in the subject line and body of your email submission.Closing Date: Open Until Filled STATE UNIVERSITY OF NEW YORK IS AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
Internal Number: 52741
About SUNY Downstate Medical Center
SUNY Downstate's College of Medicine, Health Related Professions, Nursing and its School of Graduate Studies offer students a broad professional education that will prepare them for practice or careers in any location and community. This education provides exceptional opportunities for those students with a commitment to promoting health in urban communities and addressing the complex challenges of investigating and preventing diseases that confront clinicians, educators, and researchers in such an environment. This special aspect of Downstate's unique mission is reflected in the students it attracts and selects, the vast majority of whom are drawn from the New York City Metropolitan area. Many of these students are members of minority and cultural groups underrepresented in the health professions, and/or come from families of first-generation immigrants or from economically disadvantaged backgrounds.