What are the responsibilities and job description for the Integrated Case Manager position at eTeam?
Job Summary :
The Integrated Case Manager for Population Health plays a key role as an interdependent member of the patient-centered care team. This role involves collaborative practice focused on the assessment, planning, facilitation, care coordination, evaluation, and advocacy for services to meet the comprehensive healthcare needs of individuals and families. The case manager ensures patient safety, quality of care, and cost-effective outcomes through effective communication and the use of available resources. The role is specifically designed to address the needs of patients who require complex management strategies following critical events or diagnoses, optimizing health outcomes along the care continuum. Services are provided across ambulatory, inpatient, and health plan settings.
Key Responsibilities :
- Conduct comprehensive assessments of patients and their families, addressing biomedical, psychological, social, and functional needs to understand the potential impact on recovery.
- Develop personalized, patient-centered care plans that aim to optimize the patient's care experience and outcomes.
- Engage patients and families as active participants in the care process through ongoing communication, advocacy, health education, and identification of resources.
- Use critical thinking, professional judgment, motivational interviewing, and self-management techniques to help patients overcome barriers and achieve care goals.
- Provide counseling and interventions related to treatment decisions, including advanced care planning and end-of-life issues.
- Coordinate transitions of care to ensure patients move seamlessly and safely between different care settings.
- Advocate for the appropriate delivery of services within the patient's health plan benefits structure.
- Collaborate with the treatment / care team to manage patients with complex medical and social needs, facilitating interdependent care conferences.
- Continuously evaluate the patient's response to the care plan and adjust as needed.
- Plan and participate in process improvement activities to reduce risks, including data collection, analysis, and follow-up interventions.
- Address cases involving child abuse, domestic violence, elder abuse, and sexual assault through appropriate interventions.
- Support departmental goals contributing to the success of the organization.
- Perform other duties as assigned.
Required Skills & Experience :
Schedule Details :
