As a Care Manager, you play a crucial role within our care team, focusing on actively managing a designated group of patients identified as high-risk for avoidable hospital/system resource utilization. Your primary objective will be to empower and engage patients in managing their healthcare needs effectively. This includes maintaining comprehensive patient health records, providing self-management education, and ensuring seamless continuity of care through effective care planning and transitions management.
Key ResponsibilitiesImplement and adjust individualized care plans throughout the care transition process to achieve desired patient outcomes.
Collaborate closely within a multidisciplinary team to educate patients and families, communicate with healthcare providers, and coordinate services under the Chronic Care Management program.
Conduct thorough patient assessments and liaise with attending physicians as necessary to optimize patient care.
Engage patients telephonically to establish and monitor self-management care plans, offering support and education as required.
Document all care coordination activities accurately in electronic databases, ensuring compliance with regulatory standards.
Maintain proactive communication with patients and their families, providing timely updates and responding to inquiries.
Collaborate with referral sources and stakeholders to enhance care quality and implement best practices.
Uphold patient confidentiality and adhere to HIPAA regulations and other regulatory requirements.
Demonstrate flexibility and teamwork in a dynamic, multidisciplinary environment.
QualificationsAssociate Degree in Nursing; current Registered Nurse (RN) license or equivalent.
Master of Social Work (MSW) or Licensed Clinical Social Worker (LCSW) may substitute for RN.
Minimum 3 years of clinical or patient services experience, with a focus on chronic conditions management preferred.
Familiarity with medical terminology, post-hospital care, and community resources.
Strong organizational skills, ability to prioritize tasks independently, and handle multiple requests simultaneously.
Proficiency in computer applications and electronic medical records.
Willingness to participate in ongoing education and training sessions as required.
Ability to work occasional weekends, holidays, and travel up to 10% as needed.
Preferred QualificationsBachelor Degree in Nursing; CCM certification or ACM.
5 years of experience in mental health disorders, care/utilization management, or patient-centered medical homes (PCMH).
Experience with InterQual or MCG guidelines, bilingual in Spanish, or program development skills are desirable.
Join our team and contribute to our mission of delivering exceptional care and support to our patients. Apply today to be part of a dedicated and compassionate team that values both professional excellence and personal integrity.
Employment Type: Full-Time