'ike Group
  • Central Medical Clinic
  • Honolulu, HI, USA

Overview


Central Medical Clinic (CMC) is the largest independent multi-specialty group on Oahu. We are a family-oriented, primary care focused group practice that promotes wellness for the entire family, delivers outstanding patient care, and provides a progressive and incomparable healthcare experience. We are comprised of Hawaii's leading physicians supported by compassionate and caring staff who serve you and your loved ones through every stage of life. At CMC we have a 65 year history of our family taking care of yours.

CMC is part of the 'Ekahi Health System whose vision and passion is to connect you and your family with the highest quality health care available on Oahu. To accomplish this, we've brought together some of the top performing doctors and specialists in Hawaii, as well as a nationally recognized and scientifically proven comprehensive lifestyle program - all together in one dynamic group to better serve you and your family.

Work as part of a care team within the practice to identify patients, perform Medicare Annual Wellness Visits and to work with patients on making behavioral changes to pro-actively improve patient's health.  Act as a health educator, coach, community resource referral and patient navigator.  You'll look for trends and opportunities for improvement and work toward improving overall quality metrics by closing gaps in care with the ultimate goal of achieving improved health from this population.

Under direct supervision of a physician, this position will be working directly with patients and doing their Medicare Annual Wellness Visit.  This includes a great deal of assessment and may include recommending diagnostic tests, and vaccinations. This position also is involved with developing a patient care plan in conjunction with providers.

 

Primary Responsibilities and Duties


  • Identify and reach out to Medicare patients. Schedule, perform and document Medicare Annual Wellness Visits.
  • Establish a plan of care and coordinate this with the patient, provider and payer.
  • Either in person or telephonically, assess patient's background, resources and health issues and with the patient, create a plan for implementing a healthier life style. Must also provide patient health coaching and educate patients about health improvement and help develop strategies for obtaining better health.
  • Monitor health needs of patients, follow up with care plans and educate about and coordinate community resources.
  • Communicate and collaborate with multi-disciplinary healthcare team members, with emphasis on continuity of care, to reduce or eliminate fragmentation, duplication and gaps in treatment plan.
  • Plan, implement, coordinate and identify barriers to care for patients with advanced care or social support needs. Assess, plan and communicate recommendations and reinforce the patient's plan of care.  Communicate finding back to the healthcare team, discuss goals of care with the patient, identify gaps in understanding and explain expected outcomes.
  • Facilitate patient empowerment and quality of life by promoting educated independent, patient choice on all aspects of care.
  • Maintain a comprehensive working knowledge of community resources, payer requirements and network services for target populations.
  • Function as a member of the interdisciplinary team, providing updates on trends and outcomes to the team.
  • Collaborate with community healthcare teams.
  • Work with healthcare teams on issues related to Population Health Management.
  • Other duties as assigned.

 

Desired Qualifications


 

  • Must have ability to work independently
  • Excellent communication skills
'ike Group
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