Population Health Case Management Specialist

Job Description Summary

Under the general supervision of the Director of Clinical Transformation, this role will serve as a Case Management Specialists for the Population Health team. Works in coordination with various care partners across the System to coordinate service and resources as needed to support patient care at the right place at the right time. This position will directly support Population Health clinical initiatives and the CMS TEAM program including spending time embedded at preferred SNF facilities and conducting patient outreach and care coordination both in person and via phone.

Job Description

ESSENTIAL FUNCTIONS

• Works as a member of the Population Health team
• Participates in the Population Health Ambulatory case management program
• Attends weekly Medicare meetings at assigned preferred SNFs
• Meets with and follows ACO and CMS TEAM patients in preferred SNF facilities to assure post-op protocol adherence and coordinate discharge planning
• Conducts pre-surgical outreach to CMS TEAM patients
• Escalates any patient questions/concerns to the appropriate team member
• Serves as a liaison between ED and inpatient case management teams to assist with CMS TEAM and other risk-product patient identification, screening and care planning
• Supports MIH as needed by assisting in creation of patient care plans and supporting discharge planning
• Discusses MIH with patients and caregivers when needed
• Coordinates outpatient services for ambulatory patients including specialty pharmacy, VNA, palliative care, etc
• Coordinates community SNF placements
• Serves as a population health liason to the Community Benefits Committee
• Coordinates transportation services for patients unable to secure transportation to ambulatory appointments
• Participates in education to ACO/IDN practices around Population Health clinical programs including MIH and ambulatory case management
• Develop relationships with community partners to strengthen SSH’s commitment to providing excellent care to our patients and community
• Safety Awareness – Foster a “Culture of Safety” through personal ownership and commitment to a safe environment.
• Verifies the patient using two unique identifiers.
• Complies with the current CDC hand hygiene guidelines through proper handwashing, as observed by the nurse manager and peers.
• Makes appropriate use of personal protective equipment at all times
• Adheres to universal precautions.

- Professional Development - Assumes overall responsibility for professional development by incorporating evidenced-based practice, research, and performance improvement initiatives as a part of ongoing practice.

• Technology and Learning
• Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.
• Embraces technological advances that allow us to communicate information effectively and efficiently based on role.
• Able to navigate multiple technology platforms to support work; to include Epic Clin Doc, Ambulatory Healthy Planet module, Epic Care Link, My Chart, Patient Ping, Arcadia, Tiger Connect, Zoom, Jabber and Outlook.
• Must have a smartphone mobile device available for business use which can support Tiger Connect communications at all times during work day
• Demonstrated competency in basic computer and keyboard skills required, Microsoft Office, Outlook, EPIC preferred.
• Knowledge of basic medical terminology required.

JOB REQUIREMENTS

Minimum Education - Preferred

BS in Psychology, Social Work, Communications or health related field preferred.

Minimum Work Experience

3-5 years recent healthcare experience or related field preferred. Experience working with patients and families, elders and their caregivers, and/or various other community populations desirable. Knowledge of community resources, SNF, eligibility and referral processes. Experience working with patients and families over the phone. Experience working in a team atmosphere.

Required additional Knowledge, and Abilities

Excellent communication skills required; ability to work independently and at times under stressful situations required. Ability to problem solve and follow standard workflow protocols as directed by clinical lead. Strong customer service skills both in person and by telephone required. Ability to time manage, set priorities and self-organization will be essential to success of employee. Ability to work collaboratively within a multidisciplinary team adhering to the Pillars of Excellence required. Experience working with patients with chronic health needs and their families required. Demonstrated competency in basic computer and keyboard skills required. Knowledge of basic medical terminology preferred, or completion of course within first year of hire. Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Patients, Families, Physicians, Registered Nurses, Care Managers, Social Workers, and other care team members