MAIN DUTIES AND RESPONSIBILITIES (Essential Functions of the Position):
Conducts care management follow up telephone calls post-discharge per RN direction
Conducts follow-up visits in a variety of acute and post-acute care settings to conduct assigned patient assessment tasks as determined by the RN Care Manager, when required
Fosters continuity of care by providing excellent customer service through effective communication and collaboration with all services involved
Ensures post-discharge follow-up with the community physician within 7-10 days of discharge
Provides education to patients regarding red-flag symptoms and actions to take to avoid escalation of symptoms
Reminds the patient to take his/her portable personal health record to all physician follow-up appointments
Performs medication reconciliation after follow-up physician appointments
Maintains knowledge of Medicare Regulations and restrictions related to home health and out-patient services.
Assists in program planning, development and implementation. Assist in policy development, as needed.
Establishes portable personal health record to be shared at all physician follow-up appointments
Monitors specified reports for identification of participants
Determines eligibility of potential Care Management candidates
Updates participant eligibility information as required
Enters referral for eligible participants in to the electronic medical record (EMR)
Assists in maintaining/updating admission/discharge information in the EMR
Performs other duties as assigned
Complies with applicable legal requirements, standards, policies and procedures including, but not limited to the Compliance Program: Code of Conduct, HIPAA and Documentation Standards.
Maintains a commitment to the values and mission of AccentCare Health Management