Aco Manager
11 hours ago
The role of the ACO Case
Manager is to support the Care Team
(Provider, nurse, medical assistant, other health providers and CCC's/PCC's) in
optimizing health and quality of life for individuals with multiple chronic
conditions by:
Following up on the care for ACO patients, so as to
offer management of care during intervals between face to face interactions
with the healthcare delivery system in Hospitals and Skilled Nursing Facilities
in order to facilitate patients being cared for at the lowest level of care
possible is a critical component of Care Coordination.
Coordination
of services for all patients who are part of the assigned group, which
includes:
ER diversion and Skilled Nursing Facilities patients ACO patients with multiple
(two or more) chronic conditions expected to last at least 12 months, or
until the death of the patient; Chronic conditions which
place the patient at significant risk of death, acute
exacerbation/decompensation, or functional decline;
Will provide
advocacy, information and referral services to patients and families to address
their medical and psychosocial needs in accordance with the physician's written
plan of care.
Qualifications:
Knowledge in appropriateassessment and assistance techniques. Knowledge in health
information management by appropriately charting patient data. Knowledge in the utilization
of tact. Knowledge and demonstrated
proficiency in performing clinical skills. Ability to communicate
clearly, with emphasis on excellent telephone skills. Ability to exercise
professionalism in dealing with all levels of personnel, patients, and
patients families.
Responsibilities:
Review of the patient careplans, initiation of telephone communication to the patients, discussion
of the care plan with the patient, and, clarification of expectations
related to the care plan. Creating education programs
for both staff and patients on High Risk Diagnosis Education and collaboration with Call Centers and
Office staff to triage clients Assist with implementing
telemedicine for ACO clients Handle non-appointment
related calls from assigned patients that involve care coordination,
follow-up, etc. Assist patients with
community resources as needed. Keep physician informed of
patient condition changes and potential changes in the plan of care. Provide an effective
communication link between assigned patients/caregivers and medical staff,
including relaying messages from providers, gathering information from
patients for providers, etc. Support patients and
providers in the Case Management Program, with care
compliance when such intervention requires resources, community
referrals, etc Ensure that all panel patients
are tracked for follow-up and reporting. Ensure that pertinent data
and tracking information is entered into the PM and or EMR systems. Quarterly review information
for assigned patients and verify and validate care delivered to
proactively coordinate healthcare needs. Coordinate with the medical
staff to ensure that referral care management services are provided
to patients with complex medical and/or psychosocial problems. Work with the medical staff
to develop, implement and carry out programs in chronic disease
management for patients, with such problems as diabetes, asthma,
congestive heart failure, hypertension, depression, and other
disease/condition states based on chronic disease management model. Ensure that disease and quality
data entry is up to date and use y reports to organize plan of care for
complex patients.
Education/Experience: Minimum of
two year's clinical experience, preferably in a hospital or office practice
setting working with complex medical needs clients.
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