Job Description

We are hiring for individual to support the following covered regions: North - Middlesex, Essex, & Worcester counties Central - Suffolk County Role is hybrid with limited travel in the above counties. The ideal candidate would have prior experience working with and supporting Pediatric patients and their families. This role would partner with the Pediatric Community Practices in the Central and Northen Regions. Job Overview This position delivers culturally-competent services to help patients navigate and access community services, other resources, and adopt healthy behaviors. Assists with care coordination tasks such as appointments and/or transportation (transporting patients is strictly prohibited), patient education and assistance with navigating physical and behavioral health systems, and facilitating communications with providers and other care team members. Helps patients' self-management by evaluating their needs, assisting with plan development, and working towards patient-centered goals. Job Description Minimum Qualifications *:* High school diploma or equivalent. One (1) year of experience in healthcare related field such as hospital, home health provider, or community-based agency. Valid, state-issued driver's license and reliable transportation. Preferred Qualifications *:* Associate's degree in Public Health, Healthcare, or other health science. Three (3) years of experience in healthcare related field such as hospital, home health provider, or community-based agency. Bilingual. Experience working in a multi-cultural setting. Experience working in a community-based setting. Duties and Responsibilities *:* The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned. Promotes, maintains, and improves the health of patients and their family through disease education and wellness as well as advocating for individuals with community health needs. Meets patients in their homes and perform structured assessments that include goal setting and motivate patients to meet their health goals. Establishes trusting relationships with patients and their families while providing general support and encouragement, providing social support and informal counseling using motivational interviewing and goal setting. Assists patients with completing applications and registration forms, both financial and community-based resources, such as applications for Medical Assistance and SNAP (Supplemental Nutrition Assistance Program). Refers to internal or external care management services when other issues are identified (i.e. food insecurity, domestic violence, etc.). Provides ongoing follow-up with patients via phone calls, home visits and visits to other settings where patients are located. Works closely with the medical provider to help ensure patients have comprehensive and coordinated care as well as work cooperatively with other clinical personnel assigned to the same patient as part of an Interdisciplinary Care Team. Provides consistent communication to hospital care coordinators to update and evaluate patient/family status, ensuring that provided information, and reports clearly describe progress. Reports high-risk problems including homelessness, substance abuse and food insecurity after assessment by a licensed social worker clinician. Acts as a patient advocate and liaison between the patient/family and community service agencies. Manages assigned caseload of patients and record patient information in the designated EMR (training provided) and other software no later than 48 hours after patient contact. Maintains collaborative, team relationships with peers and colleagues in order to effectively contribute to the working group's achievement of goals, and tactics to meet the overall organizational goals. Acts as a patient advocate and liaison between internal and external providers, and community resources to integrate complex services and identify gaps and challenges in care and communication. Physical Requirements: Frequent sitting, standing, and walking. Bending and frequent lifting of 30-35 lbs. Moderate noise in work environment while performing tasks. May be exposed to verbal or physical abuse from patients. Requires manual dexterity using fine hand manipulation to operate computer keyboard, writing, and cutting. Requires ability to hear, to write clearly, to read text and computer screen, and to verbally communicate in a clear and concise manner. Skills & Abilities: Lives in or familiarity with the target community and feels connected to that community. Demonstrates ability to work well with people of various ages, backgrounds, ethnicities, cultures and life experiences. Excellent interpersonal and communication skills telephonically as well as face-to-face. Strong customer service skills. Detail oriented, with strong organizational skills and multi-tasking abilities. Ability to work independently with minimal supervision and as part of a team. Knowledge of medical terminology. Very strong working knowledge and proficiency with technology and business software (Microsoft Office). Job Profile Summary ?This role focuses on providing medical and clinical support services to patients. In addition, this role focuses on performing the following Community Health duties: Delivers training, facilitates sessions, and educates the community on a variety of clinical topics. An organizational related support or service (administrative or clerical) role or a role that focuses on support of daily business activities (e.g., technical, clinical, non-clinical) operating in a "hands on" environment. The majority of time is spent in the delivery of support services or activities, typically under supervision. An experienced level role that requires basic knowledge of job procedures and tools obtained through work experience and may require vocational or technical education. Works under moderate supervision, problems are typically of a routine nature, but may at times require interpretation or deviation from standard procedures, and communicates information that requires some explanation or interpretation. Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at [email protected] .

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