* Establishes rapport with patients, family members and other professionals as the initial step toward partnership in the plan of care development.

* Provides leadership in the multi-disciplinary team within Community Care Management.

* Provides referrals to other team members as appropriate.

* Develops and maintains effective working relationships with staff, other departments, system administration/leadership, and community organizations to promote a positive image, heighten awareness and promote collaboration.

* Provides leadership for quality improvement efforts.

* Uses clinical knowledge in the patient and family assessment process.

* Conduct comprehensive individual and family assessments to identify and prioritize needs to be addressed.

* Provides emotional support to patients and family members.

* Stabilizes patients who are in crisis.

* Quickly establishes rapport with patients and families over the phone to promote quality assessment and education.

* Quickly solves problems using critical thinking skills, responds to phone emergencies and crisis situations in a timely and professional manner.

* Relates to and communicates over the phone with ill, disabled, culturally diverse, emotionally distressed patients of all ages and backgrounds.

* Conducts post visit calls for inpatient, observation, outpatient surgery and emergency department encounters.

* Evaluates post-discharge status, assess patient/family understanding of discharge instructions, review new medications and reinforce care transitions plan.

* Documents post discharge call results with pertinent information entered into the electronic health record.

* Supports patients and families as they transition through the continuum of care.

* Assists with the mitigation of risk for readmission when patients have multiple and complex needs.

* Accurately prepares documentation utilizing the electronic medical record.

* Communicates and documents assessment and ongoing needs.

* Connect patients and family members with community service providers and other community resources.

* Refers patients/families to community care network and community resources when issues arise and cannot be resolved quickly.

* 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.

* Involves law enforcement, Department of Children's Services or Adult Protective Services as appropriate to assist in addressing patient safety issues.

* Collaborates with Compliance department when appropriate.