Service Area: Boise City, OK, Hooker, OK, Hardesty, OK, Texhoma, OK
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