Complex Care Manager (Physician Practice) Part Time Days

Under the supervision of Physician Practices Quality Manager, the Complex Care Manager will be responsible for the assessment, reassessment, care planning and coordination of care and services for identified high risk patients. The Complex Care Manager will identify patients based on severity of disease, co-morbidities, self-care limitations, lack of family support, socioeconomic factors, poly-pharmacy, and healthcare utilization. Identified patients will receive proactive, relationship-based care that includes ongoing monitoring with an appropriate and effective person-centered shared care plan. Working as an integral part of the Primary Care Team, the Complex Care Manager serves a caseload of high risk patients acting as a patient advocate/liaison, taking a proactive role of overseeing the continuum of care and chronic disease management for the patient.

• Ensure compliance with policy, procedure, and regulatory requirements.
• Maintain patient’s rights and confidentiality.
• Achieve all initial and ongoing competencies and specific educational requirements.
• Ensure appropriate documentation for billing, ensuring completion to maintain ethical billing practices.

• Manage a caseload of patients by proactively identifying high risk patients, through a risk stratification process, who would benefit from Care Management.
• Comprehensively assess patient’s physical, mental, and psychosocial needs; identify needs, and implement interventions and connections with local community resources.
• Create patient-centered Care Plans, assuring patients are informed and supported in decision-making by setting SMART goals that align with patient’s quality of life and outcome priorities.
• Implement and monitor reassessment of needs, progress towards goals, providing relationship-based accountability and helping patients work through barriers and setbacks.

• Serve as patient’s primary point of contact through intentional, proactive outreach at regular intervals.
• As an integrated part of the Primary Care Team, actively facilitates communication and coordination with patient, caregivers, provider, specialist, care team members and community resources.
• Maintain timely, complete and accurate documentation in medical record, ensuring that the Care Plan is accessible to entire care team to coordinate care.