Patient Care Manager (RN or LSW)

Summary

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. Care Manager will promote self-care management and assist with access of care. Care Manager works with patients through direct face to face patient interaction or telephonically. 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.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Essential Duties And Responsibilities

• Identifies, tracks and manages care for high risk patients.
• Conducts initial care coordination screening eligibility and performs Comprehensive Risk Assessments (CRA) and Care Plans (CP)
• 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 and post discharged patient populations to complete transitions of care with in-network MHN participating hospitals (completing updated health risk assessment, communicating during and post inpatient admission, completing updated medication reconciliation, scheduling follow up appointment with primary care or specialty, and obtaining any discharge summaries)
• 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
• Coordinating care for behavioral health pediatric patients identified via MHN SASS Cares Log notifications (inpatient BH admissions and outpatient BH follow ups)
• 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 (HEDIS), medication review and reconciliation with a licensed professional for medication adjustment, and ensure care coordination across the practice and healthcare system.
• Assists with scheduling/coordinating any follow up appointments for primary care, specialty care, and other pertaining organizations as needed throughout care management services
• Assists with contacting other high risk care managed patients to request Confirmation of Informed Patient Consents for care plan approvals
• 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.

Supervisory Responsibilities

• None
  
  

Key Interrelationships

WORKING CONDITIONS:

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.

Qualifications

Education:

• Bachelor’s Degree in either social work, nursing or related title in a similar discipline
  
  

Licensure

• Licensed Social Worker or Nurse, Professional Counselor or related field
  
  

Experience

• 3-5 years of experience with 1-2 years in disease management or care management
  
  

Special Training

• None
  
  

Demonstrated Competencies

• 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
• Strong oral/written communication skills
• Bilingual (English/Spanish)
  
  

Benefits

Full-Time Benefits:

• Paid Time off (Vacation, Paid Sick Leave and Paid Leave)
• Full Health Benefits (Medical , Dental , Vision, Disability, Life Insurance. )
• 403B Retirement Plan.
  
  

Salary range$60,000.00-$65,000.00 Based on qualifications and experience.