Clinical Care Guide - Rehabilitation and Human Performance

Come join a group of smart passionate individuals who recognize business as usual is over and are together innovating a new system of care. We are looking for a Care Guide (Clinical Engagement Specialist) to join our Commercialization Operations Team focused on engaging patients and their caregivers through an episode of this role you will engage patients and caregivers as active collaborators in their care plan anticipate future needs identify and address barriers to medical care and reinforce expectations for surgery and recovery. You will work with an interdisciplinary care team navigating patients through each treatment phase ensuring optimal continuity of care smooth transitions and timely delivery of care. You will also work with the Product team to provide feedback on the patient experience in order to drive continuous improvement of healthcare solutions that deliver a great value and a best-in-class experience for our customers.

Clinical Patient Support

• Conduct psychosocial assessments with patients and family caregivers identify barriers to seeking medical/behavioral health care and work with the team and patient/family caregivers to develop a care plan to overcome these barriers and improve health outcomes
• Provide intensive post-discharge follow up with patients and family caregivers to provide support and ensure adherence to care plan with the goal of avoiding preventable avoidable ED visits and re-admissions
• Maintain a close working relationship with the interdisciplinary team to provide appropriate levels of support assisting patients to reach their goals and improving their health
• Manages completion of diagnostic testing ensures timely patient follow-up
• Assesses patient clinical status and triages patients to appropriate physicians or care providers
• Troubleshoots patient care issues and communicates with appropriate staff regarding unresolved care issues
• Responsible for navigating the patient through the continuum of care

Program Enrollment

• Outreach to potential candidates of the program for enrollment
• Engage patients and determine eligibility for the program
• Maintains an in-depth understanding of the specialty care models program and patient benefits in order to answer patient questions related to the program requirements features employer benefits etc.
• Offer educate and assist patients in procuring the appropriate patient amenities.
• Coordinate the resolution of any patient issue or concern.
• Create a network of referral providers based on appropriate criteria.
• Stays informed of the program developments and modifications and standard levels of care

Continuous Quality Improvement

• Identify strategies for improving patient outcomes
• Identify strategies for preventing avoidable ED visits and readmissions
• Identify opportunities to streamline patient care

• LMSW/LCSW licensure preferred
• 2-4 years of professional experience in a fast-paced work environment
• Experience in a hospital with patients with chronic behavioral health and medical conditions preferred
• Expert in documenting in an electronic medical record
• Proficient in Microsoft Office Suite (PowerPoint Excel etc.)
• Experience with customer service
• Bilingual (English/Spanish) preferred
• Flexible and receptive to change with the ability to learn quickly and retain new information
• Highly organized and detail-oriented
• Self-motivated team player
• Solutions-oriented thinker
• Passion for health care as evidenced by academic or personal pursuits and professional experience

Non-Bargaining Unit 857 - Rehabilitation and Human Performance - ISM Icahn School of Medicine