Practice Based Care Manager, OP

Are you an experienced Nurse looking to take the next step in your career? The Population Health department at UPMC Western Maryland has the right fit for you as a Practice Based Care Manager, OP! 

This is a Monday - Friday, dayshift position that will support our Primary Care practices.

 
As the Practice Based Care Manager, OP you will support the practice physicians in the coordination of care, developing care plans, reducing barriers to care, and providing follow-up for highly complex patients in the practice. This includes coordination of practice, community, and health insurance resources; and working closely with the patient, family and caregivers, and all involved providers, including the Expanded Care Team support staff for the patients in the practice(s).

Responsibilities:

• Once the patient is ready to leave the program, facilitate the transition back to the Primary Care Doctor of the patient.
• Meets face-to-face with patients and family members initially and as needed to build a relationship, assess the patient's medical, behavioral health, and social needs, and identify barriers.
• Works very closely with and maintains open communications with the Primary Care Physician of the extensive care program for direction and collaboration related to patient needs and assessment.
• Documents all assessments, interventions, and plans of care completely and accurately into the electronic health record.
• Assess the patient's appropriateness for enrollment into the Chronic Care Management program in terms of meeting criteria, approval by PCP, and patient and family's willingness to participate.
• In collaboration with the team, develops and coordinates an individualized plan of care with the patient, patient's family, health insurance plan, providers, and community agencies as applicable. Involves additional providers as needed to support the individualized plan of care based on the identified needs of the patient and family and/or caregiver. Plan designed to promote health, close gaps in care, and decrease unplanned care.
• Actively participates in planned team meetings to monitor patient's status, evaluate the effectiveness of the individualized plan of care, identify new needs, and strategize for next steps.
• Maintains availability to patient and /or caregiver as needed by phone or visit. Rotates call by phone according to systems developed in the practice for Chronic Care Management program.
• Follow up with patient and/or caregivers regularly to assess patient's medical status or compliance to plan or to offer assistance as needed.