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Care Manager
3 months ago
Job Summary:
Under direction of the Director of Value Based Care, the Care Manager is responsible for triaging, coordination, documentation, communication, and tracking of patient calls, cases and records for a panel of medium acuity Traditional Medicare and Medicare Advantage Plan patients in the Chronic Care Management (CCM) Program.
The Care Manager is responsible for ensuring that patients with chronic conditions in his/her care are provided with CCM services in an appropriate and timely manner.
Chronic Care Management services provide a minimum of 20 minutes per calendar month of non-face-to-face communication (electronic or phone) with patient (or HIPAA Rep) and clinical staff, physician or other qualified health care professionals.
However, the frequency and length of calls is not limited to 20 minutes each month and is conducted as the patient's medical condition warrants.
During this call an initial Care Plan is established and implemented, or the annual Comprehensive Care Plan is reviewed and/or revised and documented in the patient's chart.
A Comprehensive Care Plan is an electronic summary of the patient's physical, mental, cognitive, psychosocial, functional, environmental and social assessments.
It contains a record of all recommended preventive care services, medication reconciliation with review of adherence and potential interactions and oversight of patient self-management of medications, an inventory of clinicians, resources, and supports specific to the patient; including how the services of agencies and/or specialists unconnected to the designated physician's practice can be coordinated.
It includes ensuring that ER and hospital clinical documents, consult notes and other records of care are current and available on the chart for review as needed.
The Care Manager coordinates efforts with the Quality Department to ensure that each patient is accurately assessed, and that Annual Wellness Visits are completed quality measures and gaps are closed.
He/she accurately updates patient's problems list, diagnoses, health conditions, mediations list and Care Team and brings additional medical concerns to the primary care provider as needed.
- This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice._
Essential Duties and Responsibilities:
- Works closely with the Director of Value Based Care and/or the Lead RN Care Manager to provide CCM services primarily to a medium acuity panel of Traditional Medicare and Medicare Advantage plan patients who are assigned to his/her care.
- Demonstrates personal effectiveness and credibility, collaborative skills, communication proficiency and flexibility and strong decision making and documentation skills.
- Works closely with the Director of Value Based Care and/or the Lead RN Care Manager, other CCM team members, providers and Quality staff to help ensure that the care patients receive is efficient, thorough, timely and properly documented to help patients avoid ER and urgent care visits, hospital admissions and readmissions. Assists in ensuring the best quality of life possible for each patient in their care.
- Provides and oversees regular communication and collaboration with the patient's Primary Care Provider, clinical staff, specialists and pertinent outside care services for the benefit of the patient.
- Works closely with the Quality Improvement Manager and team to assist and facilitate that Annual Wellness Visits are completed and gaps in care, social determinant needs are documented and addressed and quality measures are met for the wellbeing of Care Management patients.
- Facilitates and executes care management strategies for the care coordination of CCM Patients, including utilization of other population health initiatives, including communications with patient's designated representatives and pertinent clinical staff.
- Works with the Director of Value Based Care and/or the Lead RN Care Manager, the Quality Improvement Manager and the MSRs to identify specific patient social and preventative care needs. Facilitates resolutions when possible with resources throughout an assigned geographic area.
- Knows, understands and works within the scope of his/her practice. Seeks advise and/or help from management whenever needed. Able to delegate responsibilities appropriately to staff licensure, education, and experience.
- Participates in pertinent meetings, workshops, seminars, and related forums as directed.
- Provides regular reporting of activities and statistical data and status of CCM patients in his/her care to the Director of Value Based Care and/or the Lead RN Care Manager as directed.
- Responsibilities include a rotating "oncall" schedule determined by the Director of Value Based Care and/or the Lead RN Care Manager.
- Maintains con
