Value Based Care Specialist

SUMMARY

The VBC Specialist is responsible for providing education, counseling, advocacy, and coordination of services to patients belonging to customers using the eClinicalWorks & healow product suite. The VBC Specialist will act as an extension of the patients Care Giver or Primary Care Provider (PCP) in helping to close the gaps in patients care. This individual will build rapport with patients through one or two virtual sessions each month supporting them through services such as Chronic Care Management (CCM), Behavioral Health Integration (BHI), Principal Care Management (PCM) and Remote Patient Monitoring (RPM). Furthermore, the VBC Specialist will empower patients to meet their goals, guide them in their healthcare journey, advocate for their needs by utilizing active listening skills, investigating patient concerns, documenting appropriately, and communicating professionally with the patients care. The VBC Specialist will collaborate directly with multiple primary care office-based health care teams to provide patient-centered care and frequent follow-up with Patients and Providers.

RESPONSIBILTIES

• Directly interfaces with patients using technology, telephone, email and text messaging to support patient self-management and support for the various chronic disease management programs (CCM, RPM, etc.).
• Provides education, coordination and support to patients on the follow-up and management of their chronic illness.
• Contributes to monthly, quarterly and annual reporting as required for eClinicalWorks / healow and for program certification.
• Utilizes care management plans, interventions, treatment goals and other products / features within the eClinicalWorks & healow product suite for patient-specific documentation.
• Adheres to and ensures compliance with CMS standards on chronic care management and follow-up.
• Works with the respective Team Lead, primary care providers, care center staff, and nurse managers to:
  • Collaborate with patients and families to provide high quality patient assessments.
  • Use motivational interviewing techniques to assist patients with adhering to self-management goals and action plans with timeframes.
  • Ensure timely implementation of assessments, care plans and appropriate interventions for identified patient populations to determine health, social situation, physical environment, mental health, substance abuse, economic status and educational needs of patients.
  • Leverage the eClinicalWorks & healow product platforms to identify chronically ill patients and opportunities.
  • Identify utilize cultural and community resources to assist patients, and to maintain an accurate database of services and contact information of such resources.
  • Arrange contact with other resources needed to support patient treatment plans.
  • Utilize evidence-based educational offerings and care plans for chronic diseases such as diabetes, obesity, hypertension, asthma, depression and COPD.
• Delivering excellence in preventative care services to enhance overall health outcomes for chronically ill patients.
• Identifying health risks
• Identifying gaps in care and patient risks.
• Connecting patients to the resources and support they need.
• Reviewing of the patients medical, functional, and psychosocial needs.
• Medication reconciliation with review for adherence.
• Encouraging and facilitating timely receipt of all recommended preventive services.
• Reinforcing disease self-management education and preventive care guidelines.
• Communicating primary care team instructions and advice.
• Providing patient education materials.
• Referring to and coordination with community service organizations.
• Notifying patients of lab results, any changes in provider orders, specialist appointments, etc. and document notification in the eClinicalWorks EHR or healow solutions.
• Managing care transitions between healthcare providers and settings, including assistance with referrals to outside providers, follow up after hospital or emergency room visits, or stays in skilled nursing facilities.
• Facilitating patient follow-up visits with PCP for acute or chronic needs.
• Documenting all concerns and follow-up and escalate to the Nurse Care Manager, Clinical Team, or PCP when appropriate.
• Enabling better overall patient outcomes.

The ideal candidate must be able to:

• Understand the various value-based care and population health management programs (such as CCM, RPM, APCM, BHI, PCMH, etc.) prevalent in the healthcare industry.
• Manage and support patients' healthcare needs via telephone, televisit, email and or text conversations.
• Ensure that daily productivity goals and quality metrics are met within the standards established.
• Oversee complete individualized patient care plans and perform care management and care coordination services via the eClinicalWorks & healow software platforms.
• Maintain contact with patients one or two times each month to provide care coordination, support, and manage compliance with the care management programs to increase positive outcomes.
• Ensure that there is optimal documentation of all communications with patients, their caregivers, and their providers accurately with the Electronic Health Records (EHR) system.
• Ensure timely communication to and from primary care teams regarding patient needs and/or life-threatening episodes and ensure comprehensive care plans are complete and accurate.
• Ensure adherence to documentation protocols and best practices for daily workflow, escalation of client issues, comprehensive care plans, and internal communications.
• Demonstrate excellent customer service skills demonstrated by positive feedback from customers and patients.
• Speak to the benefit and value of Chronic Care Management, Remote Patient Monitoring and other similar programs, to ensure patient enrollment and retention goals are met.
• Continuously educated themselves with the latest updates on the various industry-standard programs for value-based care.

QUALIFICATIONS

• An LPN, MA, CA, or RN degree with at least 2 years' work experience in your role.
• Familiarity with Chronic Care Management, Remote Patient Monitoring or similar value-based care programs.
• 1 - 2 years of experience and proficiency working with Electronic Health Records (EHR) software as a user.

PREFERRED QUALIFICATIONS

• A positive attitude.
• Empathetic and active listening skills with the ability to thrive independently in a fast-paced environment.
• A quiet, uninterrupted dedicated workspace ensuring HIPAA compliance is met as well as reliable high-speed internet.
• Knowledge of healthcare terms, conditions, roles, and basic care principles
• An ability to develop and build trusting relationships with patients and partner practices
• Demonstration for a passion for caring for patients and guiding them in their health journeys
• Ability to stay flexible and quickly adapt to new processes, software changes, and priorities
• Ability to pass a background check
• Willingness to learn new skills on a continuous basis