Peekskill, NY30+ days ago
Obtains consultant reports, medical record releases and consents • Accountable for managing an outreach schedule for patient follow-up and appointment setting, while providing care coordination with both internal and external stakeholders • Evaluates and assists patient with overcoming barriers to obtaining necessary appointments and medical care • Screens patients for factors influencing social determinants of health and initiates referrals using appropriate resources • Consults with transition of care team and seeks clarification when needed; identifies and escalates encounters that require complex care or medical triage • Participates in development and implementation of patients Transition of Care Plan, coordinating with nursing, to meet established goals • Identifies, refers, and maintains continuity of care for patients requiring high-risk care management, while collaborating with licensed clinical staff • Monitor and coordinates treatment plans as indicated by licensed clinical personnel • Identifies, refers, and maintains continuity of care for patients requiring high-risk care management, while collaborating with licensed clinical staff. Responsibilities: • Facilitates bidirectional information exchange with hospital and primary care provider/team • Performs rounds to hospital where indicated to meet with patients, admission personnel, case managers, discharge planners, others • Performs outreach follow-up for patients who have had a recent discharge, including but not limited to: inpatient hospital discharges, emergency room visits, postpartum units, skilled nursing and rehabilitation facilities • Responsible for appointment setting, referring patients to appropriate agencies, specialty providers, and community resources • Obtain hospital records and ensures records are received (scanned/e-faxed) in eCw.