Adult Complex Care Manager

About the role

A Complex Care Manager is accountable and responsible for coordinating or evaluating the cases for patients with multiple chronic conditions, high-risk health concerns, readmission, or denial of patient status. You will strive to achieve optimal clinical and quality outcomes by effectively managing care and resources to reduce unnecessary utilization.

Responsibilities

• Conducts EMR reviews and/or patient interviews via face-to-face and/or telephonic engagements to assess, identify, and address clinical and non-clinical gaps in patient care.
• Performs readmission reviews to evaluate contributing factors and implement strategies to reduce avoidable hospitalizations.
• Manages denial cases, including reviewing medical necessity, collaborating with physicians and payers, and advocating for appropriate patient care coverage.
• Facilitates complex discharge planning, ensuring safe and effective transitions of care for patients requiring specialized placement or services.
• Assists with the collection, analysis, and benchmarking of utilization, process, and outcome metrics to identify trends and areas for improvement.
• Analyzes productivity measures and evaluates the effectiveness of care management strategies in achieving clinical, financial, and patient-centered outcomes.
• Researches, evaluates, and recommends resources to meet medical and non-medical needs of patients and families.
• Utilizes clinical expertise and understanding of care management, Medicare regulations, and contributes to the goals of cost containment and quality care and provides safe and appropriate transitions of care.
• Collaborates, refers, and communicates across all programs to ensure appropriate coordination of services.
• Works collaboratively and maintains active communication with physicians, nursing, and other members of the interdisciplinary team to effect timely and appropriate patient management.
• Serves as an advocate, placing the needs of patients and their families first. Delivering compassionate care that is whole person care: body, mind, and spirit.
• Supports shared decision making and encourages patient adherence to their care plans.
• Promote patient and family responsibility and self-management.
• Conducts EMR reviews and patient interviews via face-to-face and/or telephonic engagements to assess, identify, and close clinical and non-clinical gaps in patient care.
• Evaluate changes in patient-reported symptoms and conduct additional triage and screening to determine next steps.
• Assists with the collection, analysis and benchmarking of utilization, process, and outcomes metrics.
• Analyses productivity. Measure outcomes and effectiveness of care management including clinical, financial, quality of life and patient/family satisfaction. Identifies opportunities for continuous improvement.
• Participates and promotes performance improvement projects.
• Serve as liaison between patients, families, and healthcare providers.
• Supervise and mentor students.
• Represent the care management department in hospital committees and task forces.

Qualifications

• Nurses: Bachelor of Science in Nursing (BSN) required.
• Social Workers: Graduate of an accredited school of social work. License Master Social Worker (LMSW) under supervision or Licensed Clinical Social Worker (LCSW) required.
• At least 5 years Care Management experience, 1 in an acute or ambulatory care setting.

Skills

• Professional demeanor.
• Self-directed.
• Ability to work as a member of a team.
• Excellent verbal and written communication (including documentation) skills.
• Detailed - oriented with excellent organizational skills.
• Commitment to fostering a culture of continuous learning, quality improvement, and patient-centered care.
• Strong assessment, critical thinking, and problem-solving skills.
• Strong knowledge of healthcare regulations, including CMS guideline.
• Show clear understanding of utilization management principles and integrate these with care management responsibilities.
• Serve as liaison between patients, families, and healthcare providers.
• Excellent organizational and project management abilities.
• Knowledge and skill in chronic disease management.
• Strong organizational and time-management.
• Ability to assess, adapt, and calmly respond to changing and crisis environment.
• Ability to facilitate patient access to community resources.
• Proficiency in utilizing electronic health records (EHR) and care management software.