Arrives to work on time or notifies Patient Care Manager or designee as soon as employee becomes aware that s/he will be absent or tardy, and/or as per individual department protocol Maintains an acceptable attendance record as per CareMount Medical policies and procedures Notifies Patient Care Manager or designee whenever leaving CareMount Medical premises during schedul

Performs an initial comprehensive assessment on all newly enrolled patients and provides ongoing care thereafter. Develops a patient management care plan upon enrollment and updates it as needed when changes in condition warrant or following hospitalization. Meets with patients and/or their legal representatives to review newly developed or modified care plans; involves t

Prepare examination rooms and sterilize medical equipment Room patients, obtain health history, check vital signs and perform EKG's Administer injections and collect specimens Document patient care using electronic medical record software Schedule appointments, complete prior authorizations, process medication refills, handle referrals, answer calls and complete paperwork

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Independently collaborates effectively with Interdisciplinary care team (ICT) to establish an individualized transition plan for members Independently serves as the clinical liaison with hospital, clinical and administrative staff as well as performs a review for clinical authorizations for inpatient care utilizing evidenced based criteria within our documentation system

Provides medical care and management to members served by the program and participates in gathering clinical information for medical necessity determinations for service requests. Works with the Landmark Health Medical Director, Director of Health Services, Corporate Director of Health Services, and UM staff in the development and/or implementation of medical management p

Practices in accordance with the respective state laws and regulations governing the practice of advanced practice nursing Understands and complies with long term care policies and procedures, including those that regulate nursing facilities and assisted living communities Establishes and maintains effective relationships with members and their legal representatives, faci

Conducts medical home visits on established Bridges in Complex Care patients performing a hands on exam at each visit Conducts urgent / acute visits on established Bridges in Complex Care patients with the goal of keeping the patient out of the hospital in order to receive the best medical care at home Provides ongoing assessments of the impact of life limiting chronic il

By serving as the link between patients and the appropriate health care personnel, the SICC is responsible for ensuring efficient, smooth, and prompt transitions of care Perform Skilled Nursing Facility (SNF) assessments on patients using clinical skills and utilizing CMS criteria upon admission to SNF and periodically through the patient stays Review targets for Length o

Uphold and model Our Cultural Values Adhere to all applicable laws and ethics (HIPAA (Health Insurance Portability and Accountability Act), Exceptions to confidentiality, Reporting Abuse, Duty to Warn etc.) Answer calls/chats within standard service levels Apply sound clinical judgement and consult with fellow clinical professionals when indicated Triage calls/chats based

Primary Care Delivery Deliver cost effective, quality care to assigned members Manage both medical and behavioral, chronic and acute conditions effectively, and in collaboration with a physician or specialty provider Perform comprehensive assessments and document findings in a concise/comprehensive manner that is compliant with documentation requirements and Center for Me

Manage chronic illnesses in a complex elderly population with multimorbid conditions focused on wellness, avoiding unnecessary hospitalizations and ER visits, providing patient education about disease processes, improving overall quality of care, and increasing patient satisfaction in the healthcare system Document timely with an added focus on closing HEDIS quality gap m

Practices in accordance with the respective state laws and regulations governing the practice of advanced practice nursing or physician assistants Establishes and maintains effective relationships with patients, care givers, and/or their legal representatives, IDT members, PCPs, other collaborating physicians/providers, and facility staff when applicable Performs an initi

Demonstrates clinical competence in the direct care of patients in established area(s) of practice, and assisting MDs with procedures Performs clinical duties within scope of practice complying with the accepted CareMount Medical and/or individual department standards, policies, and protocols Demonstrates a proactive approach to patient care, focusing on addressing each p

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