Manager, Patient Centered Services and Outreach

Description

POSITION SUMMARY

The Patient-Centered Services & Outreach Manager also serves as the Co-Manager of Patient and Community Engagement and is responsible for leading the Community Health Workers (CHWs) and overseeing and coordinating patient-centered services in the areas of medical case and care management, lifestyle and nutrition services, as well as Alzheimer's and dementia services. This position leads various patient-, community-, and family-centered activities on behalf of The Wright Center entities and liaises regularly with the volunteer Directors of TWCPCE as well as TWCCH. An important member of the Care Management team, this position works closely with the Care/Case Management (C/CM) team, the Director of Community Outreach and Engagement (CO&E), and the Board of Directors of TWCPCE to develop, organize, and implement patient- and family-centered care improvement and wellness initiatives. The Manager is also responsible for capturing and properly documenting all clinically billable activities to promote stewardship of resources. In addition, this position supports TWC's commitment to continuously develop and enhance TWCGME's population health curriculum to ensure that America's physician workforce is both community-competent and compassionate.

To maximize the impact of this role, the Patient-Centered Services & Outreach Manager also serves in a volunteer capacity as one of three Co-Managers of Patient and Community Engagement for TWCPCE, in partnership with the Director of Community Outreach & Engagement and the Director of Patient Engagement & Behavioral Health Outreach. Affiliated with TWCCH, TWCPCE is a tax-exempt Pennsylvania nonprofit organization established to support the education of, advocacy for, and empowerment of patients and families. This position engages and organizes patients and families, staff, residents, and the community to increase engagement across all groups and improve health outcomes

REPORTING RELATIONSHIPS

This position reports directly to the Deputy Chief Nursing Officer, who provides operational oversight to ensure certified Community Health Worker services are appropriately supervised, documented, and billed in a timely manner.

In addition, the position works in close partnership with the Board of Directors of TWCPCE to support the organization's strategic priorities. While the Board does not serve in a direct supervisory capacity, it provides performance feedback regarding the position's responsibilities as a Co-Manager/Director of TWCPCE for consideration during TWC performance evaluations.

This position directly supervises the Community Health Workers.

ESSENTIAL JOB DUTIES AND FUNCTIONS

While living and demonstrating our Core Values, the Patient Centered Services and Outreach Manager will:

Care Coordination

• Partner with the DCNO and CM team to support non-clinical interventions for Geriatric, Lifestyle/Nutrition, and primary care populations.
• Design and contribute to the clinical workflow that transitions stabilized Community Health Integration (CHI) patients into long-term Chronic Care Management (CCM) programs once social barriers are resolved.
• Assess social/economic barriers to design responsive plans.
• Oversee patient access to vital community, behavioral health, and social services, removing cultural and socioeconomic barriers.
• Direct the implementation and compliance of remote patient monitoring devices to guide timely nursing interventions and proper billing regulations.
• While meeting monthly metrics, ensure that billable work of the certified Community Health Workers is appropriately supervised, documented and timely billed. 
• Oversees the certification and recertification process for Community Health Workers, ensuring compliance with all applicable requirements and timelines. 

Patient Engagement

• Takes direction from and works closely with the DCNO, the Director of BH, and the TWCPCE Board of Directors on developing, planning, implementing, and reporting on projects and initiatives arising from TWCPCE's strategic plan.
• Takes the initiative to identify and propose patient engagement events/programs based on community health needs assessments and TWCCH SDOH screens, and, once approved, develops and implements the Project Plan with Budget for approval.
• Works constructively with Practice Managers in all clinical locations to address non-medical patient complaints and concerns.
• Partners with the Marketing & Communications Department and the Director of Patient Engagement and BH Outreach on all community outreach events/projects.
• Ensures timely transfers of information and responses to patient a