Essential Job Outcomes

1. Perform Inpatient and/or Ambulatory support of all patient Case Management activities and programs including; patient outreach to initiate Case Management services, ED outreach, Care Transitions, Transplant, Dialysis and other CM programs.
2. Conduct patient outreach for MemorialCare Medical Foundation patient populations including Managed Care, Fee for Service and ACO as requested via on-site at the bedside, in the clinic/office or telephonically and via Simply Better standards and practice.
3. Support Inpatient and/or Ambulatory Case Management activities including; review of discharge instructions, orders, referral authorizations, confirm delivery or need of equipment and home health services and review medications for accuracy and refer to Pharmacy Team as needed.
4. Schedule follow-up appointment with PCP per scheduling guidelines.  Confirm follow-up appointment with specialists and assist patient with specialist appointments as needed.
5. Assist and support patient communication with Primary Care Physician, Specialists with emphasis on MyChart for ease of access and schedule appointments as directed.
6. Document all coordination of care activities within patient’s chart (EMR) and/or CM electronic system completely, accurately and within stated timeframes and workflows. Scan external records as needed.
7. Maintain logs, run reports, analyze data, monitor Care Plans and patient tracking as requested.
8. Attend and actively participate in any in-services, team huddles, educational opportunities, case conferences, team building exercises as they relate to Medical Management. 
9. Actively assist co-workers and team members as needed based on large census, staff absence or illness.
10. Perform any additional/miscellaneous duties (not inclusive of job description) as requested by the management team within the scope of knowledge/ability