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Care Coordination Manager

2 months ago

Columbia, South Carolina, United States Prisma Health Full time
Empower Health. Serve with Empathy. Make an Impact.

Position Overview

Oversees targeted patient demographics to ensure efficient and effective healthcare delivery by adhering to Case Management standards as defined by the Case Management Society of America.

Involves the coordination, facilitation, monitoring, and evaluation of interventions to achieve desired health outcomes.


Key Responsibilities

Works collaboratively as part of a multidisciplinary team to guide and track individuals across various care settings, including inpatient, outpatient, and home environments.

Ensures seamless continuity of care through established, evidence-based practices, which may include medication reconciliation, self-management strategies, family and caregiver engagement, education, and referrals.

Develops comprehensive care plans and collaborates with other team members to address any gaps in care.


Accountabilities
Facilitation of Patient-Centered Care
  • Identifies, assesses, and enrolls high-risk patients from specified populations.
  • Conducts thorough evaluations of patients' current health status, identifying barriers to optimal health and available resources.
  • Collaborates with patients/families, providers, and healthcare team members to formulate an initial Care Plan and Self-Management Plan that highlight opportunities for enhancing clinical outcomes and reducing care gaps.

Implementation and Monitoring of Care Plans
  • Coordinates patient and family involvement in the Care Plan and self-management efforts.
  • Utilizes knowledge of community resources to facilitate goal achievement.
  • Delivers patient education to support the Care Plan using evidence-based methods, such as teach-back techniques.
  • Conducts home visits as necessary to assess potential barriers to self-management goals and devises strategies to overcome these obstacles.

Interdisciplinary Collaboration
  • Participates in the creation and execution of the Care Plan across the continuum of care, including acute, post-acute, and home settings.
  • Demonstrates expertise in care management and serves as a resource for the interdisciplinary healthcare team.
  • Integrates knowledge of regulatory requirements into case management practices.
  • Collaborates with both inpatient and outpatient staff to ensure continuity of care.
  • Acts as a consistent point of contact for patients across clinical settings.
  • Facilitates referrals to other disciplines and community-based programs to enhance patient outcomes.

Evidence-Based Practice
  • Employs knowledge of efficiency and effectiveness indicators when coordinating and facilitating the Care Plan.
  • Enhances understanding of best practices and clinical standards, incorporating this knowledge into daily practice.

Documentation and Reporting
  • Accurately documents collaborative care planning, interventions, and evaluations in the medical record and on team tools, reflecting progress against defined targets and goals.

Management Responsibilities

This position does not include management responsibilities and reports to a supervisor, manager, director, or executive.


Minimum Qualifications
  • Bachelor's degree in Nursing.
  • At least 3 years of nursing experience, with a preference for 1 year in Care Management or Case Coordination.
  • Current South Carolina R.N. License.

Additional Requirements
  • Proof of current auto liability coverage.
  • Willingness to travel and possess reliable personal transportation.
  • Obtain case management certification within 2 years of hire.

Work Schedule

Day shift.


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