Population Health Patient Care Liaison-MSM-FT Days

Population Health Patient Care Liaisons coordinate appointments and other healthcare services at Mount Sinai Health System facilities and external organizations to fit the specific needs of each patient. They facilitate the delivery of preventative care services, chronic disease management services, and medication adherence assistance. They liaise between medical providers, patients, health insurance companies, and more. Patient Care Liaisons increase health literacy by educating patients on the importance of preventative screenings and procedures, chronic disease management, and medication adherence. This position promotes a high level of patient satisfaction by identifying and helping to address barriers to high quality, patient-centered care.

Description of Competencies • Facilitates timely access to primary care and specialty appointments by scheduling services related to preventive care and chronic disease management. This includes appointment reminders and addressing barriers to completing care in collaboration with the patient’s multidisciplinary team. • Advocates for patients who need additional assistance obtaining appropriate medical care. • Directs non-English speaking patients to providers conversant in their preferred language or facilitate the use of translation services. • Educates patients in the areas of health promotion, maintenance, disease prevention, and management of acute/chronic illnesses. • Encourages medication adherence for chronic disease management by pending medication refills to providers, working with pharmacies to remove patient barriers to adherence, reminding patients to fill prescriptions, and connecting patients to financial resources for medication adherence. • Partners with practice-based care team members like medical assistants, nurses, pharmacists, and supervisors to manage population health strategy for value based contracts through effective relationship building. • Assists providers by pending orders in electronic medical record for labs, screenings, and referrals to support programs. • Educates providers and practice staff on role of Patient Care Liaison, quality program guidelines, and best practice implementation. • Serves as a liaison with health insurance companies, helping to maintain accurate provider patient panels and demographic information. This includes submitting reports to health insurance companies adhering to strict coding guidelines. • Uses data reporting tools in the electronic medical record, other hospital information systems, and data provided by health insurance companies to execute a reminder system for immunizations and preventive services. • Maintains accurate and complete electronic medical records by updating Health Maintenance and locating results of care delivered outside Mount Sinai Health System by obtaining patient consent and contacting external hospitals and providers. • Identifies underlying systems problems or obstacles to the delivery of high levels of customer service and participates in continuous process improvement. • Participates in quality improvement and quality assurance activities, including forming population health strategy and creating new workflows. • Provides ongoing statistical and financial reporting of all service activities. • Participates in the development of other staff members. • May be required to perform other duties, including team cross-coverage, when assigned by manager.

Experience and Skills Required • High level of interpersonal skills and customer service required; must be comfortable dealing with a wide range of individuals including physicians, clinical and general staff, and the public • High proficiency in computer systems, especially Epic and Microsoft Excel • Fluency in multiple languages strongly preferred • Identifies and understands issues, problems and opportunities; compares data from different sources to draw conclusions; uses effective approaches for choosing a course of action or developing appropriate solutions • Logically and effectively structures tasks to work efficiently and meet deadlines • Ability to manage multiple priorities simultaneously • Critical thinking and problem solving abilities essential; must have ability to analyze a situation in order to facilitate an appropriate resolution of an identified problem • Ability to organize and present information clearly and concisely • Excellent organizational and time management skills with high attention to detail • Ability to communicate professionally and effectively both verbally and in writing • Demonstrates a humanistic, kind, and caring attitude in the delivery of health care • Displays a professional, courteous, and respectful attitude in interactions with all members of the health system staff and extended community 

Professional Development • Supports the mission, vision, values and goals of Mount Sinai Morningside and the Department of Care Transitions and Population Health • Meets regulatory and