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Job Summary

Manages targeted patient populations to achieve efficient and effective care delivery through adherence to Case Management standards as outlined by the Case Management Society of America. Includes coordinating, facilitating, monitoring and evaluating interventions to achieve desired outcomes. Functions as part of an interdisciplinary team to guide and track individuals across time and delivery sites, including inpatient, ambulatory and patient home settings. Ensures continuity of care through defined, evidence based methods, including, but not limited to, medication reconciliation, self-management plan, engagement of family and care givers, education and referrals. Develops care plan and collaborates with other care team members to address gaps in care. Promotes and facilitates improved clinical outcomes and patient satisfaction, as well as efficient use of resources.

Accountabilities

Facilitation of Patient Centered Care

1. Identifies, evaluates and enrolls high risk members of specified populations.

2. Performs complete assessment of patient's current health status, including barriers to achieving optimal health, and available resources

2. Based on assessment and in conjunction with patient/family, Provider and other healthcare team members, participates in the development of an initial Plan of Care and Self-Management Plan that highlight actual and potential opportunities for improving clinical outcomes and/or utilization patterns and decreasing gaps in care.

2. Facilitates and monitors implementation of Plan of Care.

3. Coordinates patient/family participation in Plan of Care and self management.

4. Uses knowledge of community resources to facilitate achievement of goals.

5. Coordinates patient education to achieve Plan of Care using evidence based methods such as teach back.

6. Performs home visits as necessary to evaluate possible barriers to attainment of self management goals and develops strategies to overcome barriers. 35%

Interdisciplinary Practice

1. Participates in the development and execution of the Plan of Care across the continuum of care, including acute, post acute and home settings.

2. Demonstrates expertise in care management and serves as resource to the interdisciplinary health care team.

3. Integrates knowledge of external and internal regulatory requirements into the review and management of cases.

4. Works in collaboration with inpatient and ambulatory Prisma Health staff, as well as non Prisma Health staff as necessary to facilitate continuity of care.

5. Serves as bridge across the clinical setting and functions as patient's consistent point of contact

6. Facilitates referrals to other disciplines and internal and community based programs as appropriate to improve patient outcomes. 35%

Evidence Based Care

1. Utilizes and incorporates knowledge of efficiency and effectiveness indicators (example-PQRS, NCQA, URAC and HEDIS) when coordinating and facilitating Plan of Care.

2. Increases knowledge of best practices and clinical standards of care and incorporates knowledge into practice. 20%

Measurements and Reporting

1. Documents in the medical record and on team tools, accurately reflecting collaborative care planning, interventions and evaluation against defined targets and goals. 10%

Work Shift

Location

Greenville Memorial Med Campus

Facility

7002 Value-Based Care and Network Services

Department

70028455 Care Transformation

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