Ambulatory Case Manager

Purpose of Position

The scope of the PHO Ambulatory Case Manager is to manage the PHO covered lives under risk ("PHO Members" or "Members") by reducing acute care episodes. This is accomplished by facilitating high-quality, safe and patient-centered care provided by our PHO physicians. The Ambulatory Case Manager is responsible for the timely facilitation, education and coordination of care in relation to the member's ambulatory sensitive chronic disease conditions and severity of their illness burden.

Responsibilities

• Coordinate care effectively as a team leader, working closely with the interdisciplinary team of Physician Offices to review referrals and plan and implement an individualized care plan that promotes high-quality, safe, patient-centered, and cost-effective care.
• Assess the member's care needs utilizing established standards of care and/or approved clinical guidelines.
• Exhibit a commitment to the mission and goals of the organization and demonstrate a respect for working in a collaborative decision-making process by incorporating continuous quality improvement.
• Gather and analyze specific criteria and guidelines to track and manage inpatient high risk admissions, avoidable ED visits, readmission and high cost utilization of the PHO members.
• Ensure the appropriate delivery of services through Assessment and Case/Problem Identification, Coordination, Planning, Monitoring and Evaluation.
• Facilitate the delivery of services by establishing relationships with all health care providers, health plans, facilities and community resources ensuring appropriate utilization across the continuum of care.
• Communicate in a clear and effective manner with members, their families, caregivers, physicians and other health care personnel, including members of varying educational levels, backgrounds and cognitive levels.
• Show empathy and compassion in case managing our members; make every effort to understand the circumstances affecting the member and their health care and vested interest in the wellness of the member.
• Work with the members on realistic goal setting while incorporating socio-cultural ethnic factors, support and facilitate members to move towards achieving their goals.
• Accommodate the member's preference for mode for patient education and coaching such as telephonic, in-person or video conferencing.
• Initiate an in-person visit with the member based on established case management standards of care and protocols.
• Assess the member's home environment to identify potential risks and barriers to the health and wellness and make appropriate referrals as needed.
• Adhere to defined plan of care and adjust the plan as appropriate based on the member's status and information collected upon reassessment.
• Collaborate with, and be responsible for, coordination with other disciplines participating in the Plan of Care (i.e. PCP, Specialist, Dietician, VNA, SNF/Rehab personnel, community resources).
• Participate in multi-disciplinary patient case conferences; evaluate the effectiveness of patient care.
• Reassess the plan of care at regular intervals and discharge the member when goals are met.
• Notify the Primary Care Physician (PCP) and other care providers in a timely manner of significant changes in the member's condition or care plan.
• Document the member's care in the case management systems including the development of a collaborative plan to be shared and updated with the risk member's clinical team such as the PCP and/or Specialists.
• Ensure documentation is timely, clear, concise, and addresses specifics of teaching and care coordination.
• Follow the PHO's documentation protocols to collect pertinent data supporting performance and success measures.
• Maintain medical records and medical information in a confidential manner appropriate to legal requirements and standards of good practice.
• Regularly meet with the PHO Helping Hands team and the Medical Director as needed for care collaboration, coordination and team support.
• Maintain core/clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities.
• Participate in PHO-related committees, education programs, in-services, and meetings as required.
• Demonstrate flexibility, cooperation and characteristics of a team member.
• Collaborate with Case Managers at Hospitals on large case management and discharge planning.
• Perform other related duties as assigned or requested to meet the scope of the organization's mission.

Qualifications

• Current license as a Registered Nurse in the Commonwealth of Massachusetts.
• Bachelor of Science Degree in Nursing preferred.
• Certificate in Case Management preferred.
• Demonstrates competency with a minimum of experience of 3 years in a hospital setting, home health care or outpatient Physician Office setting.
• Demonstrate recent knowledge/experience within past 3 to 4 years in: Discharge Planning; Utilization/quality management; Home care and/or Hospice Nursing.
• Ability to speak effectively before individuals and groups of patients or employees of the organization.
• Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor, with patients, physicians, fellow employees, and insurance companies.
• Excellent organization and time management skills.
• Possess skills in independent decision-making, problem-solving, independent judgement, use of critical thinking and effective communications.
• Ability to work independently and effectively in a fast-paced environment.
• Ability to work productively in a stressful environment and effectively handle multiple projects and changing priorities.
• Proficient computer skills with the ability to utilize and integrate information from multiple software and EHR systems.

Schedule

32 Hours Per Week, Monday-Friday, No Weekends & No Holidays