Pathways Health Partners - Coverage Area Ocala North or Ocala South

Job Summary

The Patient Engagement Specialist 1 (PES 1) at Pathways Health Partners plays a crucial role in ensuring the continuity of care for patients post-discharge. This position involves visiting patients at their homes, conducting follow-up calls, and providing support to ensure patients adhere to their care plans. The PES 1 must have credentials as a Certified Nursing Assistant (CNA) or Certified Medical Assistant (CMA) and a strong commitment to patient-centered care.

Role and Responsibilities

Position Competencies:

• Triage reason for ER visit and Impatient Discharge
• Assess patient(s) for healthcare access including provider appointments, pharmacy needs, and discharge care patient will require (IE Physical Therapy, etc)
• SOT – Subjective, Objective, Treatment
• Know and maintain professional communication skills: verbal, written, and non-verbal communication
• Understand and maintains the highest level of HIPAA (Health Insurance Portability and Accountability) standards

• Specific:
  • Conduct home visits to recently discharged patients to assess their health status, review discharge instructions, and ensure they have the necessary resources and support
  • Make follow-up phone calls to patients to check on their progress, answer any questions, and provide guidance on medication adherence, appointments, and other aspects of their care plan
  • Educate patients and their families on disease management, medication usage, and healthy lifestyle choices to promote better health outcomes
  • Collaborate with healthcare providers, case managers, and other members of the healthcare team to ensure coordinated and comprehensive care for patients
  • Accurately document all patient interactions, assessments, and interventions in the electronic health record (EHR) system
  • Identify and refer patients to community resources and services as needed to address social determinants of health and support their recovery
  • Act as a patient advocate, ensuring their needs and preferences are communicated and respected throughout the care continuum

• Participate in quality improvement initiatives aimed at enhancing patient engagement and reducing hospital readmissions

• Core:
  • Works well independently and has strong operational skills
  • Excels at customer service and has strong interpersonal skills
  • Strong organizational and time management skills
  • Demonstrates a positive attitude and maintains a positive corporate culture
  • Communicates effectively and has strong verbal, non-verbal, and written communication skills
  • Develops strong relationships with coworkers and other stakeholders
  • Learns quickly and has strong problem-solving and critical-thinking skills
  • Willingness to continually self-educate and grow professionally
  • Prompt and regular attendance
  • Assist and perform additional duties as asked or assigned

Qualifications and Education Requirements

• 1. Education: High school diploma or equivalent. Completion of required education program to compete certification as a Certified Nursing Assistant and/or Certified Medical Assistant
• Experience: Minimum of 2 years of experience in a clinical setting, preferably in home health, hospital, or outpatient care. Experience in patient education and care coordination is highly desirable.
• Certification/Licensure: Certification as a Nursing Assistant (CNA) or Medical Assistant (CMA) is required at time of hire. CPR/AED/First Aid or BLS certification at time of higher or within 30 days. EMT or equivalent certification highly desirable. Valid driver’s license and reliable transportation for home visits.
• TrainingandKnowledgeRequired atTimeof Hire: CPR/AED/First Aid. Excellent interpersonal and communication skills. Compassionate and empathetic approach to patient care. Proficient in using electronic health records (EHR) systems.
• AgeSpecific Individuals Served/Responsibility: Adults
• SecurityMeasures andClearance: Will require up to a Level 2 background check/clearance

• Medical Insurance for Employee and Spouse/Significant Other paid 100% by Pathways!
• Addition of family coverage for dependents at a fraction of the cost
• 25K life insurance for employees 100% paid by Pathways!
• Increasing Employee coverage or adding spouse/dependents at a fraction of the cost
• Vision and Dental Coverage available at a low cost for employees, spouses, and family
• 401K retirement plan with 100% match up to 4% of annual pay
• Paid holidays
• Ample Paid Time Off (PTO) for vacation/sick/personal days