Care Manager
4 weeks ago
The Care Manager serves as an integral part of the care team. The Care Manager will actively manage an assigned set of patients who are identified to be at high risk for avoidable and unnecessary utilization of hospital/system resources. The Care Manager will provide services to help empower and engage patients in their needs for healthcare. The services include structured recording of patient health information, self-management education and support, maintaining electronic continuity of care plan, managing transitions of care, and other care management services. The care plans will be implemented and modified as needed throughout the transition of care to ensure the patient’s achievement of the desired outcomes. The Care Manager will work collaboratively as part of the team to provide patient and family education, communication with health care providers and coordination, and facilitation of services within the Chronic Care Management program.
To be successful in this role, one must:
- Provide comprehensive care management and care coordination for a panel of high-risk patients with 2 or more chronic conditions. Coach patients to improve their health behavior to attain health-related goals.
- Use case management processes to ensure quality care is delivered to patients, families, and caregivers in the most efficient and effective manner across the care continuum and within a virtual environment.
- Complete a comprehensive patient needs’ assessment for each patient and coordinate with the attending physician as needed.
- Develop and maintain relationships among patients, families and caregivers, and the patient’s care team.
- Telephonically engage patients, families, and their caregivers in understanding, establishing, and monitoring patient self-management care plans, as warranted.
- Document each patient’s individualized care plan and care coordination in the electronic database. Proactive engagement with patients, families, and caregivers to provide education and resources throughout the full continuum of care.
- Provide timely communication with patients and identified family representatives, as required.
- Communicate with and provide feedback to referral sources including physicians, advanced practice providers, behavioral health specialists, social services, employees, stop-loss carriers, and/or care coordinators, as appropriate.
- Assist the care team by helping to measure quality and identify, refine, and implement practice improvements.
- Demonstrate personal responsibility and respect for patients, families, caregivers, and co-workers.
- Demonstrate flexibility, enthusiasm, and willingness to cooperate while working with others in multi-disciplinary teams.
- Uphold HIPAA regulations and complies with federal and state regulatory bodies to support quality measure requirements.
- Adhere to all Department procedures regarding documentation.
- Take call on weekends and holidays, as needed.
**Qualifications**:
- Associate Degree in Nursing
- Current Registered Nurse license in state of residence - compact licensure as warranted
- At least 3 years clinical or patient services experience
- At least 3 years care/utilization management, health care customer service, and/or patient-centered medical home (PCMH) background is desired
- Knowledge of medical terminology
- Excellent communication skills
- Knowledge of post-hospital care and community resources
- Ability to prioritize independently and respond to multiple simultaneous requests
- Ability to complete continuing education requirements as needed
- Ability to attend company, department, and team meetings as required, including industry training sessions
- Ability to comply with all company policies and procedures, proactively protecting confidentiality of Client and company information
- Ability to travel at least 10%
- Ability to work on a computer for a prolonged amount of time
- Ability to work outside of normal business hours as needed; weekend and holiday coverage, as assigned
- Legally able to work in the United States
**Preferred Qualifications**:
- Bachelor Degree in Nursing
- 3-5 years clinical or patient services experience
- Relevant TPA or payer experience
- 5 years care/utilization management, health care customer service, and/or patient-centered medical home (PCMH) background
- Certification in Case Management (CCM or ACM) or specialty area
- InterQual or MCG experience
- Bilingual in Spanish language
- Knowledge of medical terminology, counseling/teaching, and family treatment skills
- Aptitude for managing human behavior change
- Program development skills specific to the environment
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