Hybrid Care Manager Poughkeepsie, NY

ABOUT US

Vitability Health is leading the change in how providers deliver remote care. Our next-generation RPM Program enables medical teams to provide safe, effective care that improves patient outcomes, lowers patients’ medical expenses, empowers patients to be fearless, and live longer lives. We are a team of dedicated, mission-driven pros who seek to work with colleagues who inspire us and share our mission and core values.

JOB DESCRIPTION

As a Care Manager, you will provide Chronic Care Management and Behavioral Health Integration services to patients remotely, in their homes, and at assisted living facilities to ensure effective care coordination, patient monitoring, and overall health management.

Responsibilities

• Collaborates with physicians, providers, and practice staff to identify appropriate patients for care management
• Manages a caseload of chronic care patients, including patients with mental health issues developing and implementing individualized care plans
• Assists patients in setting SMART goals for self-management and teaches them how to do self-management tasks and report abnormal findings to their physician team
• Collaborates with the patient, physician, and other care team members in assessing the patient’s progress toward individual healthcare goals
• Provides health monitoring, behavioral health screening, and follow-up management with patients to ensure compliance with their care plan
• Educates patients through telephone advice per protocol and handles urgent/emergency calls during working hours responding promptly to any abnormal readings
• Anticipates the needs of the patient population, ensuring necessary documentation and pre-visit planning is completed or requested before patient visits
• Works with patients and patients’ care team to coordinate change readiness from various settings (hospital or skilled nursing facility discharges and emergency room visits), conduct needs assessments, develop individualized treatment care plans, and coordinate appropriate referrals as needed
• Maintains accessible, consistent documentation of patient self-management measures, and reporting progress toward goals.
• Assesses barriers when a patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments
• Coordinates disease registry activities
• Maintains a list of medical supply vendors and community resources available to patients
• Makes recommendations for policies/procedures to ensure that preventive services are offered in a timely manner to all who qualify
• May conduct home visits with a physician to assess safety, medication compliance, and home environment

Qualifications

• At least 1 year of experience as a Care Manager, CNA, or Licensed Practical Nurse is required
• Must have knowledge of the Patient-Centered Medical Home model/mission as well as knowledge of insurance industry requirements
• Must have experience with chronic disease and understand preventive care measures
• Must have experience taking vital signs
• Valid driver’s license and the ability to travel for home visits is required
• Experience working with patients with mental health issues is preferred
• Must be able to work Monday-Friday 9am-5pm
• Nursing home experience a plus
• Bilingual English/Spanish a plus

PERKS & BENEFITS

• Medical Insurance
• On-the-Job Training
• Paid Holidays
• Paid Sick Time
• Paid Time Off
• Paid Prenatal Leave
• $1000 Sign-On Bonus
• Performance Bonuses and More