General Summary:
Under general supervision by Executive Director – ACO and Value-Based Services, works with patients and their physicians on getting gaps in care filled for non-compliant patients. This may require direct communication with the patient and may necessitate visiting patients in their homes to obtain health information. This may also entail guiding patients to internal and external resources via the physician’s instructions. Exhibits exemplary customer service. Presents a professional demeanor at all times, includes adherence to professional dress code. Serves as an ambassador of Toledo Clinic, Northwest Ohio Accountable Care Organization (NWOACO) and Independence Health Senior Care Advantage (Risk-based entity) in the community. Also, serves as an ambassador for all participants in the ACO/RBE.

Principal Duties & Responsibilities:
1. perform tasks to ensure HEDIS data and reports are accurate, including investigation, auditing, and improvement opportunities.
2. Has direct contact with patients. Attempts to get missing services fulfilled to close gaps in care.
3. May require visits to patients’ homes to obtain height, weight, BP and A1Cs for patients lacking this information.
4. Will work closely with other ACO/QPD/RBE staff to route patient to appropriate resources, i.e. Social Worker, NP, Transformational Care Navigator, Clinical Pharmacist and Clinical Care Navigators.
5. Help patients in utilizing resources, including scheduling appointments, and assisting with completion of applications for programs for which they may be eligible.
6. Facilitate communication and coordinate services between providers.
7. Motivate patients to be active, engaged participants in their health.
8. Effectively work with people (staff, patients, doctors, agencies, etc.) from diverse backgrounds in reducing cultural and socio-economic barriers between clients and institutions.
9. Anticipates customer needs; looks ahead and is prepared to assist in a proactive manner.
10. Effectively operates computerized telephone equipment.
11. Compiles, maintains, and processes records, data, documentation and reports regarding calls, contacts and actions.
12. May assist with or perform research to determine solutions to problems affecting customers.
13. Assures that customer is satisfied and documents call appropriately. Follow up on all calls as necessary.
14. Initiates problem solving and pursues continuous improvement in customer satisfaction.
15. Diffuses emotion of aggravated callers by creating a partnership with the customer.
16. Maintains strictest confidentiality.
17. Must be able to multi task; speak clearly and professionally over the telephone.
18. Performs other related duties as assigned.
19. Other duties as assigned.