· Manages internal and external referrals for program enrollment
· Reviews patients’ medical record for health history and recent visit encounters
· Conducts telephone outreach and travels to home visits (within specified mile radius) to build trusting relationships
· Provides education and reinforces discharge instructions and/or plan of care to ensure patient understanding, including medication adherence
· Performs physical assessments and escalates concerns to patients’ care team, telehealth provider, or a higher level of care as needed
· Performs clinical interventions within scope of practice as ordered by care team providers
· Provides emergency care within scope of practice as a certified EMS provider while accessing the 911 system, when needed
· Conducts standardized screenings such as social determinants of health (SDOH), PHQ, and Digital Health Literacy
· Assesses home environmental conditions and makes appropriate referrals to internal departments and external agencies
· Assists with appointment scheduling and rescheduling, ensuring transportation needs are addressed
· Documents clearly and accurately in the medical record to close visit encounters
· Tracks programmatic metrics and outcomes
· Maintains safety as a primary responsibility throughout all aspects of care and travel
· In addition to the above job responsibilities, other duties may be assigned
MINIMUM REQUIREMENTS
Education: Bachelor's Degree preferred. In lieu of degree, extensive prehospital experience may be considered.
Experience: 3 years of experience in a relevant clinical environment or as a released Attendant-in-Charge with a Fire or EMS transport agency preferred.
Licensure:
PHYSICAL DEMANDS
Benefits
Comprehensive Benefits Package: Medical, Dental, and Vision Insurance
Paid Time Off, Long-term and Short-term Disability, Retirement Savings
Health Saving Plans, and Flexible Spending Accounts
Certification and education support
Generous Paid Time Off
UVA Health is a world-class Magnet Recognized academic medical center and health system with a level 1 trauma center. 2023-2024 U.S. News & World Report “Best Hospitals” guide rates UVA Health University Medical Center as “High Performing” in 5 adult specialties and 14 conditions/procedures. We are one of 70 National Cancer Institute designated cancer centers. UVA Health Children’s is named by 2023-2024 U.S. News & World Report as the best children's hospital in Virginia with 9 specialties ranked among the best in the nation. Our footprint also encompasses 3 community hospitals and an integrated network of primary and specialty care clinics throughout Charlottesville, Culpeper, Northern Virginia, and beyond.
The University of Virginia is an equal opportunity employer. All interested persons are encouraged to apply, including veterans and individuals with disabilities. Learn more about UVA’s commitment to non-discrimination and equal opportunity employment.
UVA Health includes a hospital, level I trauma center, nationally recognized cancer and heart centers and primary and specialty clinics throughout Central Virginia.
Through research and clinical trials, we stay at the leading edge of the treatments we offer.
We rank among the nation’s top hospitals because our doctors, nurses and caregivers make every effort to push the envelope of healthcare.
UVA Health consists of: