Care Manager

Position Description

This position is responsible for the assessment, care planning and coordination of care and evaluation of services for Medicare Beneficiaries aligned with the CareConnectMD DCE. This includes ongoing monitoring of an appropriate person-centered care plan, education and care coordination.

• Maintains a caseload of patients, monitoring of needs and facilitating transition of care.
• Serves as the primary point of contact throughout the treatment episode at all levels of care.
• Collaborates with the interdisciplinary team of providers, vendors, facilities, discharge planners, nurses, social workers, care coordinators, caregivers to effectively manage care plans and transition of care settings.
• Communicates regularly with the patient's primary care provider and other clinicians.
• Collaborates with nursing facility staff to ensure that patient is receiving care that is appropriate and consistent with medical necessity.
• Tracks patients' utilization of skilled Part A and Part B services in a nursing facility to include documentation of medical necessity and continued stay review.
• When a patient is in the emergency room or hospital, coordinate care with attending staff and collaborate with staff to ensure the optimal transition of care to next level of care and to the patient's residence.
• Provides oversight of medication administration for the client.
• Administers caregiver education and training: orientation, as needed, and annually.
• Acts as an effective liaison to onsite facility (hospital, skilled nursing, assisted living, memory care, and mental health) to ensure continuity and congruity of services in accordance with the clients Plan of Care.

Key Duties And Responsibilities

This position is responsible for the assessment, care planning and coordination of care and evaluation of services for Medicare Beneficiaries aligned with the CareConnectMD DCE. This includes ongoing monitoring of an appropriate person-centered care plan, education and care coordination.

• Maintains a caseload of patients, monitoring of needs and facilitating transition of care.
• Serves as the primary point of contact throughout the treatment episode at all levels of care.
• Collaborates with the interdisciplinary team of providers, vendors, facilities, discharge planners, nurses, social workers, care coordinators, caregivers to effectively manage care plans and transition of care settings.
• Communicates regularly with the patient's primary care provider and other clinicians.
• Collaborates with nursing facility staff to ensure that patient is receiving care that is appropriate and consistent with medical necessity.
• Tracks patients' utilization of skilled Part A and Part B services in a nursing facility to include documentation of medical necessity and continued stay review.
• When a patient is in the emergency room or hospital, coordinate care with attending staff and collaborate with staff to ensure the optimal transition of care to next level of care and to the patient's residence.
• Provides oversight of medication administration for the client.
• Administers caregiver education and training: orientation, as needed, and annually.
• Acts as an effective liaison to onsite facility (hospital, skilled nursing, assisted living, memory care, and mental health) to ensure continuity and congruity of services in accordance with the clients Plan of Care.

Education And Experience

• Licensed Nurse (LVN or RN)
• At least 2 years of experience in case management for value-based care (health plan, delegated provider group, ACO, etc.)
• Experience in working in a post-acute setting is a plus
• Experience in working with frail, medically complex patients
• Works with Microsoft 365 (Microsoft word, excel, powerpoint, Teams meetings, calendaring)
• Well versed in navigating and documenting electronic medical records
• Current/Valid state driver's license and insurance

Benefits And Salary

This position reports directly to Senior Medical Officer. Allowances for mileage. Employer provided laptop and cell phone. Vacation/Holidays/PTO. Location: Combined in office (Costa Mesa, CA) and remote work Monday to Friday.

Essential Skills And Abilities

• Thrives in an unstructured, start-up environment.
• Self-starter that can work independently and collaboratively, prioritize tasks and has initiative and excitement to take on unfamiliar tasks.
• Working knowledge of company policies, procedures, and operations.
• Excellent composition, grammar, and business language skills.
• Excellent communication and interpersonal skills with the ability to effectively communicate with all levels of management.
• Creative, flexible, well organized, resourceful and detail-oriented.
• Excellent judgment in handling confidential and sensitive information.
• Ability to work independently, set priorities and handle multiple tasks with a high level of efficiency.
• Ability to establish and maintain cooperative working relationships with others.
• Ability to work across locations and time zones.
• Exceptional critical thinker.

Core Competencies

• Customer focus.
• Manages ambiguity.
• Collaborates.
• Drives results.
• Team player.

Company Policies

To ensure the health and safety of our workforce while doing our part to protect those around us, CareConnectMD is requiring proof of full COVID vaccination for employees as a condition of employment, subject to legally recognized accommodations.