Care Manager - Geriatric

This role requires travel between two different offices in Ann Arbor and Livonia. This role will be completely located on-site .

Highly preferred : minimum of 2 years recent geriatric experience

The Care manager will be working in IHA Senior Primary Care clinics, maintaining a panel of geriatric patients in an effort to decrease utilization and improve patient outcomes for this population. The care manager will be responsible for completing a comprehensive assessment and developing a care plan and goals in collaboration with the patient, caregiver and physician. The care managers panel will primarily comprise patients that are transitioning from one level of care to another, have multiple complex medical diagnosis, and require support with coordination of services and education of patient / caregiver in collaboration with PCP and specialists.

POSITION DESCRIPTION :

The Care Manager I is an integral member of the office patient care team. Provides care management and care coordination for patients that are experiencing a transition of care, undergoing treatment or have moderate to complex illness, while working under minimal supervision.

ESSENTIAL JOB FUNCTIONS :

• Collaborates with members of the health care team and patient to ensure the delivery of quality, efficient, patient centered, and cost-effective health care services.
• Assists patients who are at risk for developing chronic conditions to minimize these risks by providing self-management support and patient education; empowers patients to manage their health.
• Provides targeted interventions to avoid hospitalization and emergency room visits; in specialty population the care manager ensures proper triaging of the patient and appropriate delivery of care in accordance with established protocols.
• Assesses, plans, implements, monitors and evaluates delivery of individualized patient care with the goal of optimizing the patient’s health status.
• Serves as an active member of the office-based care team and works closely to support identification and referrals of eligible patients for care management support.
• Participates in the outreach and engagement of patients that are hospitalized to assist with the transition of care and provide support and education to avoid further readmissions.
• Coordinates the care and services of selected member populations across the continuum of care, promotes effective utilization and monitoring of health care resources and assumes a collaborative role with all members of the healthcare team to achieve optimal clinical and resources outcomes.
• Maintains the ability to utilize guidelines and standards of care for management of chronic diseases.
• Makes “cold calls” and engages patients into the program effectively.
• Identifies common populations / high volume complex populations within the practice and prioritizes and directs interventions. Clinical work entails :
• Coordinates and provides patient education for common patient populations within the office.
• Designs individual plan of care for patients based on evidence-based guidelines.
• Fosters a team approach by collaborating / referring patients to supporting members of the care team (RD, CDE, pharm, panel manager etc.) and ensures coordination of services.
• Assesses health behavior and disease-specific risks; identifies a plan of action for patients.
• Assures clinical compliance with follow through utilizing reminders, follow-up calls, patient, and office education.
• Refers selected patients to determined community resources and coordinate with these resources.
• Provides patient-specific feedback to providers and clinical team.
• Provides face-to-face and telephone interactions with patient population.
• Utilizes relevant computer information support including the EMR and any other care management and / or clinical IS systems needed to complete the tasks of clinical care and performance reporting.
• Works with patients and providers to customize services that will best meet the needs of the patient and work within their benefits.
• Researches and facilitates services for patients outside of their benefits while utilizing community services and resources.
• Assists in orientation process by having new CM shadow.
• Provides feedback on the CM orientation process.
• Evaluates and manages daily workflow and adjusts as needed to increase efficiency.
• Attends required meetings and training; participates in committees as requested.
• Assists with special projects and performs other duties as assigned and works within the scope of RN licensure.

Additional Essential Job Functions for those working on Specialty Teams -

Home Based Care Team :

Behavioral Health Team :

ORGANIZATIONAL EXPECTATIONS :

MEASURED BY :

Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position. Care Management Metrics including productivity and ACP education and completion, and others defined by program.

ESSENTIAL QUALIFICATIONS :

EDUCATION : Bachelor of Science degree in Nursing (BSN), Associates Degree in Nursing with extensive nursing experience. Completion of self-management support training preferred.

CREDENTIALS / LICENSURE : Valid, unrestricted RN license in the State of Michigan; valid CPR certification. CCM / CCP certification preferred.

MINIMUM EXPERIENCE : 3-5 years of experience with primary care / ambulatory care, home health agency, Behavioral Health, skilled nursing facility, or hospital medical-surgical, within the past five years. Care management experience preferred. Experience as participant in continuous quality improvement preferred.

POSITION REQUIREMENTS (ABILITIES & SKILLS) :

MINIMUM PHYSICAL EXPECTATIONS :

MINIMUM ENVIRONMENTAL EXPECTATIONS :

This job operates in a medical facility and requires regular walking to various locations around the hospital / clinic. Employees will be working where there is patient care equipment. Hazardous materials, including blood borne pathogens and bodily fluids present. Exposure to sharps, x-rays, patients' conditions, and some unpleasant sights, smells and contagious diseases is possible. This position requires significant interaction with people (many of whom are scared, hurt and / or ill) which can be stressful and result in competing priorities.

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