About This Role
This remote position involves performing video visits for patients, with occasional in-person requirements for meetings, testing, and potential visits within a designated geography. The role focuses on providing comprehensive patient care through telehealth, ensuring proper levels of care, patient safety, and avoiding unnecessary hospitalizations.
Responsibilities
- Participate in the development of clinical programs, pathways, protocols, and documentation tools
- Collaborate on the content of policies and procedures
- Conduct initial transitional care visits, follow-up visits, and change in condition visits
- Create and approve plans of care upon patient enrollment for RPM/CCM
- Review and update plans of care monthly, or as needed with changes in condition
- Oversee and review readings and staff interaction notes monthly
- Communicate with primary care physicians (PCPs) via clinical notes after each patient interaction
- Communicate with Home Health or Hospice clinical teams regarding visit findings/outcomes via clinical notes
- Make phone calls for urgent, time-sensitive issues in addition to notes
- Ensure proficiency in industry best practices for treated diagnoses
- Assess patient status during every visit and reassess the level of support and care as needed
- Maintain proficiency in knowledge of eligibility for all levels of care, including Home Health, Hospice, Palliative, and SNF
- Timely communicate and resolve issues identified during visits with PCP, clinical team, and patient/family
- Ensure proper level of care, patient safety, and avoidance of unnecessary hospitalizations
- Leverage home diagnostic and treatment capabilities to advocate for patients who can be safely managed at home
- Review Advanced Directives and initiate discussions around Goals of Care in collaboration with patient, family, PCP, and other clinicians
- Record timely (same day or within 24 hours) and accurate documentation of all encounters in the appropriate platform and EHR
- Train and ensure compliance with protocols by any additional providers
- Exercise necessary cost control measures
- Strive to provide and maintain positive external and internal customer service and promote a culture of excellence
- Demonstrate effective communication skills by conveying necessary information accurately, listening effectively, and asking questions when clarification is needed
- Plan and organize work effectively and ensure its completion
- Demonstrate reliability by arriving to work on time and taking breaks in the expected time frames
- Meet all productivity requirements
- Demonstrate team behavior and be willing to promote a team-oriented environment
