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Care Manager, Population Health

3 months ago

Ossining, United States Open Door Family Medical Centers Full time
Job DescriptionJob Description

Open Door is seeking a Care Manager, Population Health to work in our Tarrytown, NY Headquarters. The Care Manager, Population Health (CMPH) utilizes a data driven, population health approach to ensure that Open Door patients receive high quality, coordinated and patient-centered health services. The CMPH will be responsible for reviewing population health data to identify patients at increased risk of poor health outcomes. The CMPH will work closely with medical providers, care coordination staff, and other care team members to provide impactful care management interventions. The care manager will primarily provide services to patients in our Alternative Payment Model programs (APMs). As part of the medical care team, the services provided by the Care Manager, Population Health aim to improve patient health outcomes and assist patients in taking control of their health care and becoming independent, and informed consumers of health care services. Primary responsibilities include data review, outreach, coordination of population health activities, conducting needs assessments for individual patients, developing care plans and engaging patients in care.

DUTIES AND RESPONSIBILITIES

POPULATION HEALTH DUTIES

  • Review multiple population health data registries to identify high risk patients; collaborate with supervisor and care teams to develop plan to address identified gaps
  • Outreach patients and coordinate care to address gaps in care
  • Lead the Annual Wellness Visit (AWV) process by identifying patients due for these visits
  • Outreach patients to schedule AWVs and conduct Health Risk Assessments
  • Provide care coordination to support patients in overcoming barriers identified from Health Risk Assessments
  • Coordinate with Care Managers serving ACO participants to ensure that ACO deliverables are met
  • Serve as a liaison and coordinate with the ACO lead agency
  • Support administrative and compliance tasks for Alternative Payment Model contracts
  • Perform internal chart audits
  • Other duties as assigned

CARE MANAGEMENT DUTIES

  • Outreach individuals and engage them in care management services
  • Conduct assessments to identify patients’ individualized needs related to psychosocial wellbeing, physical health, and social determinants of health; utilize standardized assessment tools; monitor needs on an ongoing basis
  • Collaborate with patients to develop care plans; engage patients in the goal setting process and utilize
  • Motivational Interviewing and other techniques to assist in goal achievement
  • Coordinate and arrange for the provision of medical, behavioral health and other relevant services
  • Outreach patients after hospital events to provider Transitions of Care (TOC) services
  • Accompany patients to appointments as needed; model and coach on medical/behavioral health visit navigation with the aim of empowering patients to become independent, effective health care consumers
  • Support patients in adherence to treatment recommendations from medical and behavioral health providers
  • Provide psychoeducation using one-on-one teaching, written and printed materials, and technological tools to assist patients in understanding their physical and behavioral health conditions and treatments
  • Identify available community-based resources and actively manage appropriate referrals, access, engagement, follow-up, and coordination of services

CARE MANAGEMENT DUTIES AND RESPONSIBILITIES CONTINUED

  • Promote evidence-based wellness and prevention by providing health education on chronic diseases such as diabetes, asthma, and hypertension to improve adherence to prescribed treatment
  • Link patients to services based on individual needs and preferences such as peer support programs, support groups, smoking cessation, and self-management programs
  • Discuss advance directives and health care proxies with patients, their families, or caregivers as appropriate
  • Maintain a caseload of ACO participants
  • Maintain electronic medical records in compliance with Open Door’s standards as well as Joint Commission standards and applicable city, state, and federal laws
  • Complete all documentation as required for the ACO and other APMs
  • Participates in staff development programs, educational activities, seminars, and training opportunities
  • Participate in internal and external case conferences
  • Other duties as assigned

QUALIFICATIONS

  • EDUCATION: Bachelor’s Degree in nursing, social work or a healthcare related area preferred; will consider candidates with other relevant degrees/certifications including Registered Nurse, Licensed Practical Nurse, or Medical Assistant
  • 3+ years’ experience in care management, healthcare, and/or social services settings
  • Experience with electronic medical records is preferred
  • Knowledge or experience in case management and care coordination is preferred

SKILLS

  • Fluent in English and Spanish
  • Strong interpersonal skills including excellent active listening and clear oral communication skills
  • Engaging, warm and caring personality
  • Strong customer service, patient-centered orientation
  • Empathetic and driven to assist patients
  • Passionate about providing high quality care to low-income, under-served individuals and those lacking access to health care
  • Able to function effectively as a member of an interdisciplinary team and committed to collaborative team-based care
  • Able to navigate healthcare and community settings as well as patients’ natural settings (i.e., place of residence)
  • Culturally competent/sensitive (racial, ethnic, linguistic, LGBTQ+, physical ability, etc.) and committed to inclusive, multi-cultural programming
  • Comfortable providing direct patient care to patients of all ages with chronic medical and behavioral health needs
  • Proficient computer use, including Microsoft Office applications
  • Proficient with Excel spreadsheets; ability to perform basic functions and basic data interpretation
  • Strong writing and reading skills
  • Able to understand and follow detailed instructions
  • Highly organized and self-directed, able to multi-task
  • Flexible and exhibits the ability to adapt as situations evolve
  • Comfortable working in a fast-paced, high accountability environment
  • Effective in problem solving and exhibits excellent judgment and the ability to prioritize

REQUIREMENTS

  • Must have valid New York State driver license and daily access to car

There are many fantastic benefits to a career at Open Door Family Medical Centers. In addition to working to effect positive change in the health and lives of thousands of residents in our communities, Open Door offers its employees a stimulating, diverse and team-based work environment with comprehensive benefits including medical, dental, life insurance, flexible spending accounts, 401(k), generous paid time off, and educational assistance. Aside from excellent benefits, we offer a competitive salary and annual bonuses based on organizational and individual objectives.

At Open Door, we enjoy working in a team-based, patient-centered environment and value the benefits of a diversified workplace that values our patients and the communities we serve. If you want to make a difference in the lives of thousands of patients and if thisposition speaks to your capabilities, experience and commitment to improve the health of our communities, please submit your resume and cover letter with salary requirements.

Open Door is an Equal Opportunity Employe

Company DescriptionOpen Door Family Medical Center provides health care and wellness programs to individuals and families in need throughout Westchester, Putnam, Ulster and Dutchess Counties. A pioneer Federally Qualified Health Center, Open Door provides more than 300,000 patient visits annually and serves nearly 60,000 individual patients who might not otherwise have access. Open Door offers integrated services and a holistic approach to building healthier communities. Primary medical care, dental care, integrated behavioral health care, clinical nutrition, wellness programs, and chronic disease management are the foundation of its clinical programs.

Founded as a free clinic in 1972, Open Door’s mission of building healthier communities through accessible, equitable, culturally competent health care has led to site and service expansions. Today, Open Door operates centers in Brewster, Mamaroneck, Mount Kisco, Ossining, Port Chester, and Sleepy Hollow, in addition to eight School-Based Health Centers in the Port Chester and Ossining School Districts, a mobile dental van in Mount Kisco, and a new dental practice in Saugerties, NY. For more information, please visit our website at www.opendoormedical.org.Company DescriptionOpen Door Family Medical Center provides health care and wellness programs to individuals and families in need throughout Westchester, Putnam, Ulster and Dutchess Counties. A pioneer Federally Qualified Health Center, Open Door provides more than 300,000 patient visits annually and serves nearly 60,000 individual patients who might not otherwise have access. Open Door offers integrated services and a holistic approach to building healthier communities. Primary medical care, dental care, integrated behavioral health care, clinical nutrition, wellness programs, and chronic disease management are the foundation of its clinical programs.\r
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Founded as a free clinic in 1972, Open Door’s mission of building healthier communities through accessible, equitable, culturally competent health care has led to site and service expansions. Today, Open Door operates centers in Brewster, Mamaroneck, Mount Kisco, Ossining, Port Chester, and Sleepy Hollow, in addition to eight School-Based Health Centers in the Port Chester and Ossining School Districts, a mobile dental van in Mount Kisco, and a new dental practice in Saugerties, NY. For more information, please visit our website at www.opendoormedical.org.