The Care Manager is responsible for coordinating screening and providing the intervention of patients with identified complex chronic care needs. Acts as a connector between patient needs and the resources provided by the care management program. Provides guidance and leadership in the care management program to those in the healthcare organization as well as ensuring the patients receive the best possible care. Essential duties and responsibilities will include:
Identifies, tracks and manages care for the highest risk patients
Develop positive relationships with patients and the PCP’s caring for them
Implement strategies and evidence-based practices that are required to achieve practice transformation
Responsible for interaction and communication with patients, their families and caregivers which will occur when meet with them face-face and/or if they visit them at their homes to complete various aspects of the care mgmt. program
Expected to develop positive relationships with community agencies and other local resources that will be of benefit to the patients with whom they are working
Lead and coordinate the CM process
Responsible for overseeing the development and implementation of an integrated care plan for each medium and high-risk patient
Focus on using behavioral patient activation interventions, including motivational interviewing and self-mgmt support
Identifies and completes outreach for the inpatient & inpatient discharged populations to complete transitions of care with in-network MHN participating hospitals.
Conducts initial care coordination screening eligibility and preforms comprehensive risk assessment
Ongoing clinical assessment, monitoring and follow up for the high risk patients
Utilize standing orders and clinical orders for chronic disease management within scope of clinical practice
Assesses psychological needs and ability to benefit from community resources and referrals to outside agencies/programs when appropriate
Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
Patient teaching regarding preventative care ‘pay-for-performance’ measures, medication review and reconciliation with a licensed professional for medication adjustment, transition mgmt. and ensure care coordination across the practice and healthcare system.
Care Manager is the lead team member for communication with the patient’s care delivery system
Participates in the evaluation of the care management programs
Collaborates and participates in the selection, development and maintenance of patient education materials related to healthy lifestyle changes and specific disease management topics.
Assists in the maintenance of the patients health, wellness and prevention of secondary disease complications by providing education, counseling and support
Handles protective health information in a manner consistent with the Health Insurance Portability and Accountability Act (HIPPA)
Other duties and responsibilities as directed
Social Worker or related title in a similar discipline
3-5 years of experience with 1-2 years in disease management or care management
Proficient in Electronic Health Record, MHN Connect, Microsoft Word and Excel
Displays strong time management and organizational skills in a high intensity work environment.
Demonstrates problem solving, decision making, and sound judgment as well as customer service skills.
Exceptional organizational and interpersonal skills, with attention to detail required; strong oral/written communication skills is a must.