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:
Identifies, tracks and manages care for high risk patients.
Conducts initial care coordination screening eligibility and performs comprehensive risk assessments and care plans
Provides ongoing clinical assessments, monitoring and follow up for high risk patients
Develops positive relationships and communication with patients and their primary care provider with completing various aspects of the Care Management program.
Focus on using behavioral patient activation interventions, including motivational interviewing and self-management support
Identifies and completes outreach for the inpatient & inpatient discharged populations to complete transitions of care with in-network MHN participating hospitals.
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
Communicate with both Rush 4C Complex Care Management (Adults) & La Rabida Complex Care Management (Children) as needed for referred patients.
Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
Providing assistance with preventative health care ‘pay-for-performance’ services, medication review and reconciliation with a licensed professional for medication adjustment, and ensure care coordination across the practice and healthcare system.
Participates in the evaluation of the care management program
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
This position requires compliance with all of Alivio’s written standards, including its Standards of Conduct, Joint Commission standards, all policies and procedures and Corporate Compliance requirements. Compliance will be considered as part of the regular performance evaluation.
OSHA Category 3 – Involves no regular exposure to blood, body fluids, or tissues, and tasks that involve exposure to blood, body fluids, or tissues are not a condition of employment.
Bachelor’s Degree in either nursing, social work or related title in a similar discipline
Licensed Social Worker or Nurse or related field
3-5 years of experience with 1-2 years in disease management or care management
Proficient in Electronic Medical Record, MHNConnect
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