ACO Certified Community Health Worker- MSRDP Business Operations
Department: MSRDP Mngd Care Cntrctng Admin
Full/Part Time/PRN: Full-Time
Experience and Education
2.Work closely with patients under the direction of the ACO Nurse and Physician to ensure adherence to medical visits, including appointment reminders if necessary. Help patients access and utilize available resources, including scheduling appointments and assisting with completion of financial applications, as applicable.
3.Provide ongoing follow-up, basic motivational interviewing and goal setting with patients and families as defined in their plan of care. Follow-up with patients via phone calls or home visits as necessary. Document activities, service plans and results in an effective manner while strictly adhering to the policies and procedures in place. Be responsible for providing consistent and regular communication to the ACO Nurse and other members of the care coordination team for ongoing evaluation of the patient/family status.
4.Motivate patients to be active, engaged participants in their health through active follow up in accordance with the plan of care.
5.Build and maintain positive working relationships with the patients, providers, and nurses.
6.Continuously expands knowledge & understanding of community resources.
7.Provides patient education for chronic disease and prevention, both with ACO patients as well as in community settings.
To the extent provided by applicable law, no person shall be excluded from participation in, denied the benefits of, or be subject to discrimination under any program or activity sponsored or conducted by The University of Texas System or any of its component institutions, on the basis of race, color, national origin, religion, sex, sexual orientation, age, veteran status, or disability.