* Evaluates attributed patients identified for possible surgery and provide clinical care management risk attribution.

* Performs psychosocial assessments and develop care plans with identified patient to lower risk threshold for care delivery.

* Evaluates the progression of care by advancing the care plan identification of outcomes, implementation plan and sets goals.

* Utilizes hospital, community and national resources to maintain and enhance knowledge and expertise of the case management team.

* Provides support after discharge from post acute to ensure compliance and support occurs to avoid readmission or poor quality outcomes.

* Documents in the EMR.

* Collaborates with surgeons, care team and external providers.

* Coordinates care with the multidisciplinary team, including care coordination, pre-admissions, preoperative education and the specialty practices.

* Serve as a clinical resource with expertise in specialty care management and functions across the health care continuum.

* Prepares, and maintains clinical and office supplies and equipment for treatments.

* Cleans, and sterilizes equipment, instruments, and work areas.

* Documents patient information in the electronic medical record.

* Communicates patient concerns or significant changes in patient’s health status to the physician or allied health professional.

* Demonstrates knowledge of care management concepts for relevant specialty patients and care delivery.

* Demonstrates an understanding of the Unit's Standards of Care and Practice and Administrative Policies as well as being able to locate Policy and Procedures Manuals on the assigned units.

* Focuses on personal development areas, engaging in professional/collegial interactions with peers and students.

* Responsible for reporting any safety-related incident in a timely fashion through the Midas/RDE tool; attends all safety-related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.

* Stays current and complies with state and federal regulations/statutes and company policies that impact the employee's area of responsibility.

* If required for the position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.

* Completes all company mandatory modules and required job-specific training in the specified time frame.