Chronic Care Manager
2 weeks ago
Vitability Health is leading the change in how patients receive quality care.
Essential Duties and Responsibilities:- Manage a caseload of assigned patients with chronic conditions, including those with mental health issues.
- Collaborate with physicians, providers, and practice staff to identify patients for care management.
- Develop relationships with patients as an integral member of the care team.
- Provide follow-up management to ensure patients comply with their individual care plans.
- Maintain availability for telephone advice and handle urgent and emergency calls during working hours.
- Anticipate patient needs, ensuring necessary documentation and pre-visit planning is completed or requested before patient visits.
- Promote patient self-management and empower patients/families to achieve maximum levels of wellness and independence.
- Determine and coordinate appropriate referrals as needed.
- Work with patients and their care team to coordinate change readiness, needs assessment, and develop individualized treatment care plans.
- Collaborate with patients, physicians, and other care team members to assess patient progress toward individual health care goals.
- Maintain accessible, consistent documentation of patient self-management measures and reporting progress toward goals.
- Assist patients in setting SMART goals for self-management, teaching them how to perform self-management tasks, and report abnormal findings to their physician team.
- Assess barriers when patients have not met treatment goals, are not following treatment plans, or have not kept important appointments.
- Participate in regular team meetings and peer review activities.
- Promote collaborative teamwork and work with peers in a team situation.
- Collaborate with payer Case Managers for additional services when appropriate.
- Maintain a list of medical supply and community resources available to patients and maintain collegial relationships with frequently used entities.
- Make recommendations for policies/procedures to ensure preventive services are offered in a timely manner to all who qualify.
- Provide follow-up in transitions of care from various settings (hospital or skilled nursing facility discharges and emergency room visits).
- Coordinate disease registry activities.
- May conduct home visits with a physician to assess safety, medication compliance, and home environment.
- Participate in departmental and organizational committees as applicable.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this job.
The Case Manager must have knowledge of the Patient-Centered Medical Home model/mission as well as knowledge of insurance industry practices and requirements.
He/she must have an understanding of chronic disease and preventive care measures.
Must have a bachelor's degree in healthcare administration, health informatics, or a related field and hold licensure as a Licensed Practical Nurse, or an incumbent holding licensure as a Licensed Practical Nurse and having significant experience in chronic care may be considered.
Licensure as a Registered Nurse is preferred. Experience working with patients with mental health issues is preferred.
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