POSITION DESCRIPTION:

The Care Manager is an integral member of the office 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:

1. Collaborates with members of the health care team and patient to ensure the delivery of quality, efficient, patient centered, and cost effective healthcare services.
2. 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
3. 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.
4. Assesses, plans, implements, monitors, and evaluates delivery of individualized patient care with the goal of optimizing the patient's health status.
5. 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.
6. 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.
7. 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.
8. Maintains the ability to utilize guidelines and standards of care for management of chronic
9. Makes "cold calls" and engages patients into the program effectively.
10. Identifies common populations/high volume complex populations within the practice and prioritizes and directs interventions.   Clinical work entails:
11. Coordinates and provides patient education for common patient populations within the office.
12. Designs individual plan of care for patients based on evidence-based guidelines.
13. 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.
14. Assesses health behavior and disease-specific risks; identifies a plan of action for patients.
15. Assures clinical compliance with follow through utilizing reminders, follow-up calls, patient and office education.
16. Refers selected patients to determined community resources and coordinate with these resources.
17. Provides patient-specific feedback to providers and clinical team.
18. Provides face-to-face and telephone interactions with patient population.
19. 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.
20. Works with patients and providers to customize services that will best meet the needs of the patient and work within their benefits.
21. Research and facilitate services for patients outside of their benefits while utilizing community services and resources.
22. Assists in orientation process by having new CM shadow.
23. Provides feedback on the CM orientation process.
24. Evaluate and manage day to day workflow and adjust as needed to increase efficiencies.
25. Attends required meetings and training, and participates in committees as requested.
26. Assists with special projects and performs other duties as assigned and works within the scope of RN licensure.

• In addition, for those working on the Home Based Care Team:

1. Performs assessments of the home and social determinants of health for individuals aged 65 or older.
2. In collaboration with the Home Based NP and/or primary care physician the care manager works to implement a plan of coordinated care that supports the individual's goals, strengths and preferences.