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

IV. Required Education, Certifications, Skills & Abilities: • Appropriate degree, certificate or licensure by the South Carolina Board of Nursing as a medical assistant (MA), medical office assistant (MOA), nursing assistant (NA) or a licensed practical nurse (LPN) • Ability to work cooperatively with patients and health care staff members in performance of assigned duties V. Additional Requirements: • Must be willing to work with SMF EHR • Must have a valid driver's license • Must be willing to work at different SMF locations if requested • Computer literate in a PC environment, including the ability to end and access data relevant to program, required to include SMF EHR system VI. Training Requirements: • The Medical Case Manager will be responsible for attending all mandatory training, including evidence-based approaches to self-management support, proactively addressing the needs of patients and families in the community, culturally competency, effective communication, care coordination, HIPAA and EHR, etc. VII. Physical Requirements: (Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions) • Ability to sit and/or stand for long periods of time • Constantly operates a computer and other office productivity machinery, such as a calculator, copy machine, and computer printer • Ability to physically write and visually read