Position Summary

Committed to the constant pursuit of excellence in improving the health status of the patient and decreasing hospital readmission rates, ensures the safe and effective transfers of patients across the care continuum, serving as the bridge between the professional staff in a care setting, (e.g. hospital), the patient and/or family and the community healthcare provider. Informs and guides both staff and patients working to ensure an effective care transition from the hospital to the patient’s home; helps teach and train patient self-management skills as well as enhancing patient-healthcare provider communication; and provides support to ACTIVATE staff, Hospital personnel and community partners in the field, and provides assistance by phone or in-person to high-risk beneficiaries by identifying social determinants of health and connecting them to community services.

This position does not have direct reports.

Essential Functions:	% of Time
Enrollment Runs and screens daily census reports for potential patient enrollments Meet with patient/family at hospital bedside to introduce the program and gather enrollment data Reinforces program enrollment and patient responsibilities with the patient and caregiver Prioritizes referrals and activities according to intensity, need, and required follow-up working to ensure outcomes are met	20%
Advocacy Ensuring professional boundaries are maintained with all aspects of patient’s interaction and care delivers patient care advocacy to include: Serves as a Patient Care Advocate to the patient, coaching the patient and caregivers in addressing social determinants of health Provides information and navigation to the patient and/or family for an effective care transition, improved patient self-management skills and enhanced patient-healthcare provider communication Evaluates aspects of each patient’s condition, diagnoses, medications, and support systems to formulate an individualized plan which will lead to successful outcomes in: medication self-management use of a dynamic patient-centered record appropriate primary care and specialist follow-up knowledge of red flags · Serves as a liaison between primary care providers, and community resources on behalf of patients to ensure patient-centered coordination of care Works in the hospital and community, makes rounds in the hospital, makes home visits and follow-up phone calls Acts as a continuing resource for the hospital personnel, patients and/or caregivers	45%
Data Collection & Custodian of Records Completes the necessary assessments and referrals by collecting data on clinical indicators Maintains databases on ACTIVATE-enrolled population ensuring accurate and timely documentation	20%
Continuous Improvement & Quality Ensures compliance with all AllThrive 365 policies, procedures, and practices regarding the Activate Transitional Care program, and other contract and licensure requirements laws related to patient confidentiality, release of information, and HIPAA; and applies knowledge to the work in accordance with quality standards Uses safe work practices Promptly reports workplace and patient safety issues to supervisor Attends and actively participates in initial and on-going training and development programs and opportunities, weekly unit meetings all staff meetings, and demonstrates learned concepts on the job Participates in assigned work teams, as requested and appropriate Engages in continuous improvement efforts, as assigned, and strives to continuously improve the quality of care and self Communicates daily and as necessary with colleagues, supervisor, leadership and medical staff	10%
Miscellaneous Building, cleaning, and organizing durable medical equipment Other duties as assigned	5%

Requirements

Education & Experience, Knowledge/Understanding

Bachelor’s Degree in Social Work, Human Services, Psychology or Public Health or Nurse (LPN or RN) Licensed by the Arizona Board of Nursing
Minimum of 2 years of working with patients in a primary care setting or related work experience
Valid AZ driver’s license and acceptable MVR
Valid CPR/First Aid Certification or ability to obtain within 30 days of position entry
Must be at least 21 years of age
Clear fingerprint background screening through the Department of Public Safety and comprehensive background clearance

Skills

Excellent verbal, written, reading, and listening communication skills to include communicating clearly, effectively, tactfully, and patiently to a diverse population
Strong interpersonal skills and demeanor with the ability to build rapport and garner trust with others
Accurate keyboarding skills
Strong planning, organization and time management skills in order to meet deadlines
Proficient in the use of healthcare data management systems such as CarePort, Cerner, and Apricot
Proficient in the use of a PC; in a Windows environment; in the use of the Internet; and in the use of MS Office Applications such as Outlook, Teams, and Word, and the use of SharePoint

Abilities

Ability to interact with others in a professional, respectful, positive, helpful manner, promoting trust with others, and build and maintain strong, effective working relationships with internal and external customers
Ability to follow-up and follow-through with strong attention to detail
Ability to follow oral and written instructions
Ability to maintain patient confidentiality, privacy and dignity at all times
Ability to work both independently and collaborative as part of a team
Ability to travel up to 50% of the time within the Greater Metropolitan Phoenix area using personal vehicle properly insured
Ability to solve problems by applying analytical skills to include:
1. collecting and reporting information
2. Identifying trends and exceptions
3. investigating to define problems more accurately
4. sorting information in order of importance
5. identifying relationships and linkages between components
6. identifying variable potential causes and effects
7. soliciting guidance to define criteria and assign values of importance and urgency
8. escalating issues of an exceptional nature
Willingness and ability to embody AllThrive 365’s core values:
1. COMPASSION
2. GROWTH
3. RESILIENCE
4. OPENNESS

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position.

The work environment characteristics described are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Normal office environment; clinical or patient care setting to include hospitals, physician offices, clinics and patient homes.

While performing the duties of this position, the employee is regularly required to: talk and hear, including over the telephone, in normal range; use hands to finger, handle or feel objects, tools/equipment or controls; sit for extended periods of time, stand, reach with hands and arms, and walk. Occasionally required to stoop, kneel or crouch; lift and/or move up to 30 pounds. Vision required includes close vision, distance vision, and ability to adjust focus

Preferences

Healthcare experience
Knowledge of needs of older adults, the aging process, and the needs of adults with Disabilities, adults with traumatic brain injuries (or TBI) or SMI
Bilingual in English/Spanish

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Patient Care Advocate