Full

Philadelphia

Care Coordinator

The NHC member will assist with providing individualized support to our patients in order to promote healthy pregnancies. Major duties will include enrolling patients in Medicaid or Pennie and providing related financial counseling; following up on missed appointments and identifying potential barriers to accessing care; coordinating testing and specialist visits with outside institutions; enrolling patients in community benefit programs (e.g., WIC, Nurse-Family Partnership, etc.); engaging in wellness education related to nutrition, exercise, and mental health; and monitoring patient panel to track progress and outcomes, including identifying patients at risk of being lost to care.

Insurance outreach and enrollment for prenatal patients:

- Member will provide enrollment assistance for uninsured/underinsured patients and their families to access subsidized, low-cost, and free health insurance programs. This will be done through Pennie (PA Marketplace, also known as “Obamacare”), Medicaid, and Children’s Health Insurance Program (CHIP). Duties will include completing applications, gathering required documents, and troubleshooting the enrollment process. Member will be trained on how to use COMPASS, Pennie, and other insurance-related platforms.

- For ineligible or uninsurable patients, member will assist with applying for other health benefit programs, such as charity care at partner hospitals.

Prenatal outreach and care coordination:

- Member will outreach to prenatal patients to ensure that missed appointments are promptly rescheduled and follow-up appointments are scheduled at appropriate times. For patients who demonstrate a pattern of missing appointments, member will identify existing and potential barriers and create a plan to address them.

- Member will conduct outreach calls as necessary to patients after delivery to assist in the scheduling of postpartum and newborn appointments.

- Member will assist patients with scheduling testing, imaging, and other related appointments at the Hospital of the University of Pennsylvania (HUP), or other locations when recommended. Member will identify potential barriers to attending recommended appointments and create a plan to address them.

Referral to community prenatal programs and services:

- Member will provide referrals to the following as appropriate: Healthy Start, Nurse Family Partnership, Mabel Morris, Philly Families Can, Cribs for Kids, SafeSleepPhilly, CHOP Car Seat Program, and WIC

- Member will follow up with both patient and referral organization/program to ensure services are rendered in a timely manner

- Member will research, outreach, and form partnerships with other organizations/programs as needed based on patient need

Capacity building:

- Members will assess current practices and materials to identify barriers most regularly faced by patient panel

- Member will develop suggestions and revisions to address barriers (ex: revise current outreach material to include a variety of languages; identify alternative methods of disseminating educational information; ensure accessibility of existing resources, etc.)

Prenatal wellness education and planning:

- Member will facilitate education related to the importance of exercise and nutrition during pregnancy

- Member will facilitate education on the risk of toxic substances during pregnancy

- In addition to patient contact during prenatal sessions, the member will work to promote the activities offered through FPCN wellness educators and nutritionists.

Prenatal panel coordination:

- In conjunction with prenatal team, member will track and monitor prenatal population quality measures and outcomes

- Member will run reports through the EMR to identify patients due for interventions or at risk of being lost to care

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