Care Continuum Partner

About the role

The Care Continuum Partner serves as the main liaison between the patient, family, and clinical team for patients and their families across the continuum of their care. At every touch point with the patient, provides the full capabilities to partner with patient and families to coordinate, navigate and schedule all aspects of their care including outpatient, procedures, community and transition of care needs to deliver an optimal patient experience. Responsible for meeting patients where they are within our physical/virtual walls and responsible for advanced level partnerships with patients including scheduling of patients appointments, and addressing the full care needs and care compliance opportunities for patients both within and outside our walls. Job Duties In collaboration with clinical care team, participates and supports in pre-visit planning to ensure smooth operation and patient flow in busy physician practice. Provides support regarding referral management and intake, scheduling, pre-certification process, follow up calls and record retrieval for timely appointments. Coordinates and schedules complex appointments for patient across their continuum of care including procedures, office visits, diagnostic testing, and other ancillary services that require coordination of multiple resources. Included but not limited to: procedures, surgery, radiology and diagnostic imaging, diagnostic testing, labs, new patient coordination and therapeutic care plans. May serve as new patient concierge role in regional or practice models. Assesses patient and family needs and supports care plan compliance. Examples include new patient coordination and intake, conducting patient outreach to follow up on patient care and appointment needs. Conducts patient outreach to follow up on patient care and appointment needs. Communicates with patient in traditional and innovative platforms including telephone, patient portal and other virtual platform solutions where applicable. Facilitates communication amongst the physician/provider, clinical care team as well as financial, outpatient, ancillary and supportive services. Provides the patient with clear instructions on how to prepare for tests and procedures and explains what to expect upon arrival per established guidelines. Provides patient with robust care continuum plan and explanation of necessary care elements. Creates a warm and welcoming environment for patients, families and staff using exceptional customer service and compassionate care skills. Connects patient and families with resources and services from both within the organization in support of their continuum of care (e.g. financial counseling, transportation support, social work, counseling, nurse navigation, nutrition services, and support groups, etc.) based on social determinants of health. Supports the care team's process to assess patient's social determinants of health and other community and psychosocial needs. Create and maintain patient records, manages visit prior authorization and referral requirements. Serves as expert and liaison to patient and family on the patient portal and medical record technology. Functions as Virtual Care Concierge partner offering assistance and guidance when appropriate. Minimum Qualifications High School Diploma/GED commitment to advance education. 2 years experience interacting with patients as part of this experience, performing at least some of these core functions and 3 years experience working within a complex health system environment or related field. High degree of accuracy and attention to detail. Enhances skills through continuing education. Ability to handle numerous tasks at the same time. Superior customer service skills. Working knowledge of basic computer functionality. Effective and