Coordinate healthcare services for Tejas Health Care (THC) patients in order to ensure a holistic, whole-person approach is taken towards providing a health home for all eligible patients. Health home is defined as “person-centered systems of care that facilitate access to and coordination of the full array of primary and acute physical health services, behavioral health care, and long -term community-based services and supports.” In addition the individual must manage the core competencies of the position to include service coordination, teaching and education, advocacy, interpersonal skills, and record-keeping.
Duties and Responsibilities
•Identify and engage care coordination patients at Tejas Health Care that have been identified as having at a minimum of at least two (2) chronic health conditions such as but not limited to asthma, diabetes, heart disease, obesity, hypertension, substance abuse disorder, or behavioral health condition; one (1) chronic condition and be at risk for another; or one (1) serious and persistent mental health condition.
•Serve as the system navigator and point of contact for patients and families for asking questions and raising concerns.
•Participate as a member of a multi-disciplinary team including representation from all Tejas Health Care services who are working toward the development and implementation of health home services.
•Coordinate with the Tejas Health Care team as needed to ensure that high risk, high volume problem prone diseases as well as preventive and health promotion needs are addressed as part of the holistic, whole-person, culturally-sensitive healthcare approach.
•Serve as the liaison between the behavioral health provider and patient to ensure that the phrenological treatment is seamless and uninterrupted.
•Teach and assist Tejas Health Care patients to better manage their diseases using realistic approaches to ensure compliance.
•Provide teaching to patients/families on an as needed basis and assist in problem solving potential issues related to healthcare.
•Negotiate on behalf of the patient, as needed, with the healthcare treatment team and the patients themselves by creating reasonable goals, clarifying issues while remaining flexible and consider culturally-sensitive and holistic alternatives.
•Completes interagency and all necessary paperwork to include interaction with primary care providers that see our patients outside of Tejas Health Care.
•Communicates effectively with other staff members, representatives of other agencies and the public.
•Adheres to the policies and procedures of Tejas Health Care.
•Performs other duties as assigned.
Knowledge, Skills and Abilities
Successfully completed training and licensure as a Licensed Vocational Nurse in the State of Texas and has current CPR certification.
Possesses good organizational skills and is self-directed.
Demonstrates flexibility and emotional control in handling difficult or stressful situations.
Proficient with computer work and an understanding of medical computer systems.
Must be able to tolerate rapid fluctuations in workload
Must be able to lift, bend, kneel, reach, push and pull loads and stand for long periods of time.
The employee must be able to lift and/or move more than 50 pounds. Requires full range of body motion including handling and lifting patients, manual and finger dexterity and eye/hand coordination. Requires sitting, standing and walking for extensive periods of time. Requires working under stressful conditions or working irregular hours. Requires frequent exposure to communicable diseases, body fluids, toxic substances, medicinal preparations and other conditions common to a clinic environment. The employee frequently is required to reach with hands and arms. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. Ability to work with a moderate noise level in the work environment is required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
The above information is intended to describe the most important aspects of the job. It is not intended to be construed as an exhaustive list of all responsibilities, duties and skills required in order to perform the work. The health center reserves the right to revise or change job duties and responsibilities as the business need arises. Additionally, this job description is not intended as an employment contract, implied or otherwise, and the Center continues to maintain its status as an at-will employer.
If the essential functions of this position cannot be performed in a satisfactory manner by the employee, reasonable accommodations may be made.