Screens potential new enrollees and evaluates and coordinates new enrollees to the appropriate Case Management Program. Assists Case Team Staff with outreach activities to support care initiatives for members throughout the care continuum.
Works with leadership to create appropriate support materials regarding program purpose, goals and objectives and deliverables.
Meets with physicians across both Geisinger and the community to share details on the program.
Identifies patients for recruitment and reviews with the appropriate primary and specialty care providers.
Completes patient outreach and formal evaluation of all potential enrollees for the program to determine participant needs and eligibility for enrollment.
Completes thorough review of all medical records including laboratory and radiology reports.
Discusses care needs with primary or specialty care providers as needed.
Interviews patient and family for in-home care needs as well as other behavioral or social gaps.
Visits patients and families in their homes, at the hospital or nursing home for recruitment into program.
Segments patients to the appropriate care team including home based medical team, community palliative care team or mobile integrated health team.
Provides formal handoff to the appropriate care team.
Schedules first visit with care team.
Establishes and maintains an effective working relationship with County Area Agency on Aging and County Assistance Office delegates to provide a streamlined enrollment application process for Community Resources.
Communicates with referral sources including physician offices, hospital discharge planning, and other community agencies for follow up in completion of the intake record.
Provides follow up communication and correspondence to complete the enrollment process.
Supports triage phone service taking acute care calls from patients and families or other care providers.
Effectively assess acute care need.
Manages gaps if able immediately.
Identifies resources needed to respond to acute care need.
Activates the correct care team or 9 as indicated by acuity of acute care need.
Participates in weekly IDT meetings being prepared to share acute care activities for appropriate patients.
Identified patterns to help the care team in Plan of Care adjustments.
Maintains documentation of enrollment process, including prospective participants within designed software programs as necessary to complete mandatory state statistical reporting functions.
Assists Administrative staff with completion of reporting requirements.
Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
Graduate from Specialty Training Program-Nursing (Required)
Minimum of 1 year-Nursing (Required)
Certification(s) and License(s)
Licensed Registered Nurse (Pennsylvania) - RN_State of Pennsylvania
We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh Food
Farmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencing
programs, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.
Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13 hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers.
What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.