Major Responsibilities:

Supports programs (i.e. Urgent Care/Walk-In, Pharmacy Auto Refill, Patient Reactivation) to promote sourcing of patients by contacting patients and scheduling them for follow-up visits and wellness exams. Promotes ancillary services, such as the Central Fill Pharmacy Program and registers patients based on needs. Communicates effectively and confidently to ensure patient comfort level in successfully scheduling follow up appointment.Reviews patient records utilizing appropriate software (IDX, Cerner, Epic) to identify patients requiring follow-up and to connect them to appropriate services.Schedules appointments utilizing appropriate primary care physician protocols to ensure accuracy in scheduling. Refers patients and schedules appointments on behalf of primary care physicians throughout the organization.Documents and tracks the results of all contacts and follow-up calls within a database and provides weekly updates to leader. Provides the highest level of patient service by problem solving, documenting patient concerns, and identifying appropriate follow-up for patients.Pulls candidacy report in EPIC on current patients with dementiaComplete a chart review to verify eligibilityWill review the Referral Queue for any referrals to GUIDE. Will provide administrative support to proactively contact patients with diagnosed dementia within the network to actively discuss GUIDE program with them for voluntary alignmentAttend weekly interdisciplinary meetings (IDT)Submit GUIDE participant-reported data such as those from the Patient Assessment and Alignment form (PAAF) and the Zarit burden.Monitor GUIDE phone number mailbox and GUIDE emailAccess data that CMS shares with GUIDE Participants, such as beneficiary-level claims, alignment data and dashboardsSend letters to approved GUIDE beneficiaries if they are participating in GUDIE- Per CMSParticipate in training/onboarding- per curriculumCollect data as needed by the GUIDE programConfirm caregiver, Medicare as primary insurance, Dementia diagnosis, and if patient is in long-term nursing facility

Licensure, Registration, and/or Certification Required:

Licensed Practical Nurse (LPN) license issued by the state in which the team member practices.

Education Required:

Associate's Degree in Practical Nursing.

Experience Required:

Typically requires 5 years of experience in a clinic environment within a physician practice.

Knowledge, Skills & Abilities Required:

Knowledge of clinical processes and procedures.Knowledge of patient focused software systems, (i.e. IDX, Cerner, Epic).Ability to efficiently enter and update database records.Excellent verbal communication skills and the ability to communicate professionally and effectively with patients.Ability to read and comprehend patient records.Demonstrated ability to work independently and be self-directed.Proficiency in the Microsoft Office (Word, Excel, PowerPoint, Access) or similar products.Ability to manage multiple tasks.Excellent customer service skills.Requires completing dementia training - 10 hoursDisplays strong phone skills

Physical Requirements and Working Conditions:

Exposed to a normal office environment.May require some travel, so there will be exposure to weather and road conditions.Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.