Medical Case Manager

I. Job Summary: Sandhills Medical Foundation, Inc.’s (SMF) Medical Case Manager is responsible for supporting day-today SMF activities to improve population health and quality improvement. This position is also a key member of our SMF Population Health team that develops implements and evaluates population health, quality and practice transformation strategies to improve the health of the patients, families and communities that we serve. II. Supervisory Responsibilities: • None III. Duties & Responsibilities: • Facilitates care transition to SMF from hospitals and emergency departments for new and established patients • Schedules patients or potential patients with identified care gaps for appointments and/or follow-up appointments in a timelymanner • Securely retrieves all relevant external correspondence and attaches to patient's Electronic Health Record (EHR) for clinician review • Meets monthly with manage care plan representatives (quality and provider) • Schedules at least 30 emergency room or hospital follow-ups within 14 days' post charge per quarter • Performs thorough follow-up on messages from clinicians, maintaining timely and accurate documentation of all Medical Case Management efforts and outcomes • Conducts huddles with health center clinic to determine which patients need to contacted • Educates patients face to face on the benefits of receiving health care related to a given measure • Involves patient and family in planning patient's care as appropriate • Educates patients and families about diagnoses and self-management tasks • Provides medication adherence counseling • Works collaboratively with clinicians and the care team to ensure patient adherence to the medical plan of care and/or evidence-based medicine guidelines, including all appropriate preventive and disease-specific screenings, interventions, and treatment goals; including self-management goals, and contact schedules • Works with patients to develop 5 care plans in EMR per quarter • Communicates with populations of patients via telephone, electronically, through correspondence or otherwise to support patient adherence to plan of care and/or evidence-based medicine guidelines • Collaborates with SMF's CQI on population health and quality improvement strategies and initiatives • Identifies linguistic needs and learning style preferences of patients; documents need as SANDILLS MEDICAL FOUNDATION, INC. Page | 2 appropriate and assists in scheduling interpretive services • Maintains confidentiality and privacy in accordance with HIPAA and SMF • Documents medications, labs, screenings, screening labs, vaccinations, immunization, and other relevant health information in EHR in a timely manner • Exhibits professional conduct at all times • Performs all duties as assigned