This position is located at our Flagstaff 4th Street Clinic and is a NON-REMOTE position.

GENERAL DESCRIPTION OF POSITION
Promotes the mission and vision of North Country HealthCare (NCHC) by collaborating within the Care Teams to provide care management services. Understand and utilize the Patient Centered Medical Home (PCMH) dynamic team approach and assist patients in optimizing health and minimizing barriers.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Provide care management, care coordination, and health coaching for the purpose of empowering patients to improve health.
• Develop, prepare, plan, and teach culturally appropriate self-management goals, health literacy, and disease prevention to particularly vulnerable populations and/or those who have multiple co-morbidities and/or are high utilization of services.
• Actively participate with the care team, supporting and engaging patient-centered, provider guided treatment goals. Create self-management goals using the foundations of Motivational Interviewing and a resiliency-based approach.
• Collaborate with patients experiencing a recent episode of care within the hospital and/or Emergency Department to assure appropriate follow-up care.
• Assist with pre-visit preparation planning for patients prior to appointment, as best practice mandates, to close gaps in care, plan for preventative care, and address any outstanding referrals.
• Document all encounters in the patient chart within the Electronic Health Record.
• Have an understanding and general knowledge of behavioral health diagnoses. Be able to create a professional rapport and supportive care within a medical setting.
• Conduct interviews to assist patients in identifying barriers to care and social determinates of health, have the ability to work within a multi-disciplinary team, and appropriately refer patients to community resources.
• Maintain a current list of community agencies and resources.
• Collaborate with Health Plans, hospital personnel, emergency room personnel, Behavioral Health Agencies, and community networks to provide optimal care management services and access to care for patients.
• Participate in the Quality Management Program through process improvement opportunities and incident reporting.
• Participate in the Compliance Program through fraud, waste, and abuse prevention, detection, and reporting.
• Other duties as assigned.
• Regular and predictable attendance.
• Continuous learning in both personal and professional development.
• Consistent review, comprehension and reply of company email and related correspondence.

North Country is a VEVRAA Federal Contractor and Equal Opportunity Employer. North Country HealthCare follows CDC guidelines and federal mandates and requires vaccination against COVID-19 of all its employees. Medical and religious exemptions to this policy are requested and reviewed on an individual basis.