Patient Care Facilitator (Lpn Or Medical Assistant) - University Health Network

University Physicians' Association, Inc. Knoxville , TN 37902

Posted 2 months ago


Job Type



The Patient Care Facilitator works in partnership with the Patient Care Coordinator (RN and SW), Pharmacist, Transitional Care Coordinator, Community Resources, and UHN Network Providers to improve health and reduce health care costs for chronically ill or "high-risk" patients, non-chronically ill patients but "high-risk" due to social barriers, and their family/caregiver(s), and patients that have recently been discharged from an acute care hospital or skilled nursing facility.

Position requires normal business hours Monday-Friday. This position offers the option to be remote with occasional on-site meetings. Candidate must be able to maintain HIPAA privacy requirements when working from home. Candidate must be located in the Knoxville, TN region.

Essential Duties & Responsibilities

Serves as the contact point, advocate, and informational resource for patients, family/caregiver(s), PCP, payers, and community resource

  • Completes Transition of Care calls for patients that have discharged from a hospitalization or Skilled Nursing Facility stay; calls other patients that are assigned by supervisor

  • Reconciles medications and notifies PCP if discrepancies noted

  • Reviews discharge instructions or primary care/specialists' instructions and confirms patient understanding

  • Identifies any changes in condition since discharge or last office visit and reports to the PCP any changes in health status

  • Reports to the Patient Care Coordinator any changes in health status and asks for guidance

  • Completes screening for Social Determinants of Health

  • Follows algorithm for barrier interventions when applicable

  • Facilitates follow-up appointment with PCP or specialist

  • For complex issues found, refers patients/families to appropriate UHN resource for specific barriers to health, i.e., Pharmacist, Social Worker, PCP, Chronic Disease Management Program, and/or Transitional Care Coordinator

  • Educates patient/family how to determine appropriate level of care, i.e., ED, Urgent Care, Primary Care Provider, etc.,


  • Works efficiently

  • Completes daily assignment and notifies Supervisor in prompt manner if facing a barrier that will prevent this from happening

  • Understands goal on the average completion of as many "successful" calls as possible to match daily assignment and need to replace unsuccessful calls with overflow patients as indicated

  • Completes accurate documentation


  • Identifies and utilizes all members of Team to meet patient's needs

  • Follows instructions given by supervisor

  • Demonstrates qualities that are respectful and professional to all team members

  • Asks for help

  • Share best practice examples with other Team Members

  • Demonstrates communication style that is professional, respectful, collaborative, supportive and meant to facilitate teamwork

Maintains HIPAA guidelines for privacy

  • Respects the privacy of all patients 100% of the time

  • Obtains consent to release protected health information

  • Understands and abides by the HIPAA policy set forth by UHN

  • Reports all HIPAA issues to the Office Supervisor

Key focus on improving health for the patients and reduced health care costs for the managed population of patients.

  • Assist with the identification of "high-risk" patients (the chronically ill and those with special health care needs)

  • Increase utilization of preventative care

  • Reduce emergency room utilization and hospital admissions

  • Improves outcomes in patients referred to UHN

  • Meets productivity goals of department

  • Professional communication style



  • Licensed or credentialed as Medical Assistant or Licensed Practical Nurse (MA/LPN)

  • 1 to 2 years' experience in clinical or community resource settings.

  • Proficiency in communication technologies (email, cell phone, etc.)

  • Highly organized with ability to keep accurate notes and records

  • Experience with health IT systems and reports is desirable

  • Local knowledge about and connections to community health care and social welfare resources is desirable

Special Skill Requirements

  • Core values consistent with a patient- and family-centered approach to care

  • Demonstrates professional, appropriate, effective, and tactful communication skills, including written, verbal and nonverbal

  • Demonstrates a positive attitude and respectful, professional customer service

  • Acknowledges patient's rights on confidentiality issues, maintains patient confidentiality at all times, and follows HIPAA guidelines and regulations

  • Proactively acts as patient advocate, responding with empathy and respect to resolve patient and family concerns, and recognizes opportunities for improvement to meeting patient concerns

  • Proactively continues to educate self on providing quality care and improving professional skills

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