Case Management Specialist and Skilled Nursing Facility Liason

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 Popul