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.
Will follow role assignments that are in alignment with the Patient Centered Medical Home Standards, and participate in all Patient Centered Medical Home efforts
Identifies, tracks and manages care for the highest risk patients
Conducts initial care coordination screening eligibility and performs comprehensive risk assessment
Oversees in the development and implementation of an integrated patient care plan for each of the highest risk patients.
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.
Performs medication review, reconciliation and coordination with a licensed professional for medication adjustment
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.
Makes home visit to perform comprehensive Health Risk Assessments (HRA) to determine level of care coordination needs
Perform other duties as assigned
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)
· Nurse, RN
· 3-5 years of experience with 1-2 years in disease management or care management
· 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.
· Proficient in Electronic Health Record, MHN Connect, Microsoft Word and Excel
· Exceptional organizational and interpersonal skills, with attention to detail required; strong oral/written communication skills is a must
About Near North Health Service Corporation
Near North Health Service Corporation is an Equal Opportunity Employer. The Mission of Near North Health Service Corporation (NNHSC) is to provide access to high quality health care and to improve the health and well-being of the diverse populations and communities we serve. We are a culturally sensitive, patient centered community health center that empowers individuals through education and health prevention, regardless of one’s ability to pay.