[Hiring] Value Based Care Specialist @eClinicalWorks

Role Description

This is an entry level job. 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 patient’s Care Giver or Primary Care Provider (PCP) in helping to close the gaps in patient’s 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 patient’s 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.

• 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 and 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.
• Deliver excellence in preventative care services to enhance overall health outcomes for chronically ill patients.
• Identify health risks.
• Identify gaps in care and patient risks.
• Connect patients to the resources and support they need.
• Review the patient’s medical, functional, and psychosocial needs.
• Medication reconciliation with review for adherence.
• Encourage and facilitate timely receipt of all recommended preventive services.
• Reinforce disease self-management education and preventive care guidelines.
• Communicate primary care team instructions and advice.
• Provide patient education materials.
• Refer to and coordinate with community service organizations.
• Notify patients of lab results, any changes in provider orders, specialist appointments, etc. and document notification in the eClinicalWorks EHR or healow solutions.
• Manage 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.
• Facilitate patient follow-up visits with PCP for acute or chronic needs.
• Document all concerns and follow-up and escalate to the Nurse Care Manager, Clinical Team, or PCP when appropriate.
• Enable better overall patient outcomes.

Qualifications

• An LVN/LP or MA degree & certification with at least 2 years' work experience in your role is mandatory.
• 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.

Requirements

• 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 educate themselves with the latest updates on the various industry-standard programs for value-based care.

Benefits

• Salary Range - $45,000 - $50,000 USD.
• This role will receive a competitive salary and benefits.
• eClinicalWorks offers a rich suite of benefits which include:
• Eighteen days of Paid Time Off per year which scales based on tenure.
• Nine Paid Holidays and one Floating Holiday.
• Insurance for eligible employees which includes medical, dental, vision, basic life, short term disability, long term disability, business travel accident, and accidental death and dismemberment.
• 401(k) plan with a Company safe harbor contribution.
• Flexible Spending Account for Health Care and Dependent Care for eligible employees.
• Limited personal leave.
• Additional voluntary benefits, including additional insurance (hospital indemnity, critical illness, accident, supplemental life, short term disability buy up, pet), genetic testing, legal plan, and supplemental accidental death and dismemberment.
• Annual discretionary bonus for eligible employees.