Kansas Works Veterans Jobs

This job was posted by https://www.kansasworks.com : For more information, please see: https://www.kansasworks.com/jobs/13008468

The Patient Care Coordinator is responsible to provide timely information to clinicians, patients, and others to inform decisions about health care by implementing Clinical Decision Support Systems (CDSS). CDSS are computer-based rules that analyze data within HealthCores EHR, eClinicalWorks, to provide prompts and reminders to assist health care providers in implementing evidence-based clinical guidelines at the point of care.

Examples of CDS tools include order sets created for particular conditions or types of patients, recommendations, and databases that can provide information relevant to particular patients, reminders for preventive care, and alerts about potentially dangerous situations. CDSS offers information to clinicians and primary care providers to improve the quality of the care their patients receive. The Patient Care Coordinator will specialize in the following areas of the EHR modules: CCM, Population Health, Patient Recall, and Patient Registry.

Patient-Centered Medical Home Essential Functions:

1. Patient Population Management:

a. Provide care that is respectful of and responsive to individual patient preferences, needs, and values and ensure that patient values guide all clinical decisions.

b. Develops tools, techniques, and talking points that will aid in promoting integrated care for patients and populations

c. Oversees social determinants of health (SDOH) using the PRAPARE module and spread within health center, including consistent EHR documentation

2. Care Coordination:

a. Using established protocols and systems, outreaches to patients via phone and face-to-face interaction for chronic condition management or preventive care services, e.g. blood glucose test for diabetic patients, colorectal cancer screening, etc. Maintains documentation of contact with patients

b. Formulates and implements a care management plan that addresses the patients identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; educating the patient/family on the choices available.

c. Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues and goals.

3. Self-management Support:

a. Provide education about self-management tools patients can use and encourage patients to self-manage and promote healthy behavior changes.

b. Conduct public education outreach activities, in the form of presentations, to raise awareness about HCC and treatment options. Must have the ability to travel to various sites as required.

4. Communication Skills:

a. Assist communications in developing and implementing a quality strategy designed to further company objectives

b. Monitor analytics and create reports detailing the successes and failures of communications campaigns and strategies

5. Quality Improvement:

a. Responsible to work with Chief Medical Office and other members of the Quality Committee Team to develop, maintain, and implement plans to achieve quality improvement goals.

b. Oversees and monitors a formal quality improvement program, using CDSS, and develops performance improvement targets across the organization

Additional Essential Functionsinclude the following.

Use clinical parameters (eg., vital signs, test results) contained within the EHR to create alerts that notify the clinician or even trigger predetermined orders or order sets, diagnostic and therapeutic bundles, or clinical pathways

Use measures aim to reduce variation in clinical practice by guiding clinicians to what is considered best practice as determined by expert panels, professional associations, insurance providers

Study results of in-place clin cal surveillance systems and evaluating the potential to create measurable value propositions

Using automation to communicate directly with the patient and EHR for important, but not critical, actions.

Ensure that patient portals or text-based systems are optimized according to the need of the patients

Helps facilitates smooth transitions of care, engages patients and providers in preventative care, improves outcomes among populations, and reduces costs

Uses eClinicalWorks Population Health Management Analytics module to deliver reporting, alerting, and messaging capabilities necessary to manage population health effectively.

Uses eClinicalWorks Chronic Care Management to help providers develop care plans for patients with Chronic Conditions in order to improve health outcomes.

Manage patient enrollment and program activities

Utilized content for evidence-based care covering chronic conditions

Track time spent on non-face-to-face care with a built-in time tracker

Create, update, and maintain population health dashboards

Use eClinicalWorks Patient Registry to track, recall, and update patents UDS and/or m