Care Manager I

2 weeks ago

Ann Arbor, United States Trinity Health Full time
Heart Failure Care Manager Centralized-Remote

The care manager will maintain a panel of patients with heart failure in an effort to decrease utilization and improve patient outcomes for this population. The care manager will be responsible for proactively reaching out to patients with heart failure and providing education and making sure they have appropriate follow up with health care services, providing transitions of care for patients hospitalized or utilizing ED services with heart failure, closely collaborating with health care providers including PCP and cardiology.

POSITION DESCRIPTION:

The Care Manager I is an integral member of the office care team. Provides care management and care coordination for patients that are experiencing a transition of care, undergoing treatment or have moderate to complex illness, while working under minimal supervision.

ESSENTIAL JOB FUNCTIONS:
  1. Collaborates with members of the health care team and patient to ensure the delivery of quality, efficient, patient centered, and cost effective healthcare services.
  2. Assists patients who are at risk for developing chronic conditions to minimize these risks by providing self-management support and patient education; Empowers patients to manage their health
  3. Provides targeted interventions to avoid hospitalization and emergency room visits; in specialty population the care manager ensures proper triaging of the patient and appropriate delivery of care in accordance with established protocols.
  4. Assesses, plans, implements, monitors, and evaluates delivery of individualized patient care with the goal of optimizing the patient's health status.
  5. Serves as an active member of the office based care team and works closely to support identification and referrals of eligible patients for care management support.
  6. Participates in the outreach and engagement of patients that are hospitalized to assist with the transition of care and provide support and education to avoid further readmissions.
  7. Coordinates the care and services of selected member populations across the continuum of care, promotes effective utilization and monitoring of health care resources, and assumes a collaborative role with all members of the healthcare team to achieve optimal clinical and resources outcomes.
  8. Maintains the ability to utilize guidelines and standards of care for management of chronic diseases.
  9. Makes "cold calls" and engages patients into the program effectively.
  10. Identifies common populations/high volume complex populations within the practice and prioritizes and directs interventions. Clinical work entails:
    1. Coordinates and provides patient education for common patient populations within the office.
    2. Designs individual plan of care for patients based on evidence-based guidelines.
    3. Fosters a team approach by collaborating/referring patients to supporting members of the care team (RD, CDE, pharm, panel manager etc.) and ensures coordination of services.
    4. Assesses health behavior and disease-specific risks; identifies a plan of action for patients.
    5. Assures clinical compliance with follow through utilizing reminders, follow-up calls, patient and office education.
    6. Refers selected patients to determined community resources and coordinate with these resources.
    7. Provides patient-specific feedback to providers and clinical team.
    8. Provides face-to-face and telephone interactions with patient population.
    9. Utilizes relevant computer information support including the EMR and any other care management and/or clinical IS systems needed to complete the tasks of clinical care and performance reporting.
  11. Works with patients and providers to customize services that will best meet the needs of the patient and work within their benefits.
  12. Researches and facilitates services for patients outside of their benefits while utilizing community services and resources.
  13. Assists in orientation process by having new CM shadow.
  14. Provides feedback on the CM orientation process.
  15. Evaluates and manages day to day workflow and adjust as needed to increase efficiencies.
  16. Attends required meetings and training, and participates in committees as requested.
  17. Assists with special projects and performs other duties as assigned and works within the scope of RN licensure.
In addition, for those working on the Home Based Care Team:
  1. Performs assessments of the home and social determinants of health for individuals aged 65 or older.
  2. In collaboration with the Home Based NP and/or primary care physician the care manager works to implement a plan of coordinated care that supports the individual's goals, strengths and preferences.
ORGANIZATIONAL EXPECTATIONS:
  1. Creates a positive, professional, service-oriented work environment for staff, patients and family members by supporting the mission and values of both IHA and Trinity Health.
  2. Must be able to work effectively as a member of the clinical team.
  3. Successfully completes IHA's "The Customer" training and adheres to IHA's standard of promptly providing a high level of service and respect to internal or external customers.
  4. Maintains knowledge of and complies with IHA standards, policies and procedures.
  5. Maintains complete knowledge of office services and in the use of all relevant office equipment, computer, and manual systems.
  6. Maintains strict patient and employee confidentiality in compliance with IHA and HIPAA guidelines
  7. Serves as a role model, by demonstrating exceptional ability and willingness to take on new and additional responsibilities. Embraces new ideas and respect cultural differences.
  8. Uses resources efficiently.
  9. Responsible for ongoing professional development - maintains appropriate licensure/certification and continuing education credentials, participates in available learning opportunities.
MEASURED BY:

Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position. Care Management Metrics including productivity and ACP education and completion, and others defined by program.

ESSENTIAL QUALIFICATIONS:

EDUCATION: Bachelor of Science degree in Nursing (BSN), Associates Degree in Nursing with extensive nursing experience. Completion of self-management support training preferred.

CREDENTIALS/LICENSURE: Valid, unrestricted RN license in the State of Michigan; valid CPR certification. CCM/CCP certification preferred.

MINIMUM EXPERIENCE: 3-5 years of experience with primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical, within the past five years. Care management experience preferred. Experience as participant in continuous quality improvement preferred.

POSITION REQUIREMENTS (ABILITIES & SKILLS):
  1. Knowledge of patient care procedures and organizational policies related to position responsibilities.
  2. Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education
  3. Excellent assessment and triage skills (per specialty population expectations). Understands chronic disease management strategies and is able to implement appropriate protocols and guidelines.
  4. Proficient/knowledgeable in medical terminology.
  5. Proficient in operating a standard desktop and Windows-based computer system, including but not limited to, electronic medical records and other care management and/or clinical IS systems, email, e-learning, intranet, Microsoft Word and Excel, and computer navigation needed to complete the tasks of clinical care and performance reporting. Ability to use other software as required while performing the essential functions of the job.
  6. Excellent communication skills in both written and verbal forms, including proper phone etiquette. Ability to speak before groups of people.
  7. Ability to work autonomously and collaboratively in a team-oriented environment; courteous and friendly demeanor.
  8. Ability to work effectively with various levels of organizational members and diverse populations including IHA staff, providers, provider leadership, patients, family members, insurance carriers, vendors, external customers and community groups.
  9. Good organizational and time management skills to effectively juggle multiple priorities and time constraints.
  10. Ability to exercise sound judgement and problem-solving skills. Demonstrated skills with influencing and negotiating individual and group decision-making.
  11. Ability to handle patient and organizational information in a confidential manner.
  12. Knowledge of the compliance and quality aspects of clinical care and patient privacy and best practices in medical office operations.
  13. Ability to travel to other office/practice sites and meeting and training locations.
  14. Successful completion of IHA competency-based program within introductory and training period.

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