• 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.