Care Manager

Description

UniVida Medical Centers is seeking a Care Manager to perform care management for patients with complex and chronic care needs. This role supports and coordinates care with the patient's primary care provider and other specialists, identifies high-risk populations, conducts assessments, provides education, ensures patient access to services, implements care plans, coordinates resources, monitors inventory, assists with medical urgencies, participates in interdisciplinary care team meetings, communicates with hospitals and health plans, and performs duties telephonically or on-site.

• Support and coordinate care with the patient’s primary care provider and other specialists as applicable
• Assist with identifying high risk population (e.g., high utilizers, multiple co-morbidities, polypharmacy, non-compliant, at risk for readmission, oxygen dependent, bed and wheelchair bound)
• Conduct assessments to identify individual needs and develop a specific care management plan
• Provide patients with education on medical conditions and co-morbidities
• Ensure patient access to services appropriate to their health needs (e.g., community resources, social services, behavioral)
• Implement care plans by facilitating patient needs related to medical, psycho-social, and psychiatric needs
• Coordinate internal and external resources to meet patients' needs
• Maintain inventory on urgency medications and supplies
• Assist and coordinate care regarding medical urgencies (e.g., assisting with IV’s, wound care, medication administration)
• Participate in Interdisciplinary Care Team (ICT) meetings with patient’s provider to communicate progress and discuss complex issues or barriers to care
• Communicate and coordinate with hospitals and health plans for concurrent review
• Complete Population Health Program activities and meet Key Performance Indicators as required in policies and procedures
• Improve staff competence by providing educational resources, balancing work requirements with learning opportunities, and evaluating the application of learning to changes in treatment results
• Absorb and implement activities to promote cost savings such as potentially preventing admissions by coordinating outpatient care and reducing readmissions (target 10%)
• Assist patients with coordinating care pertaining to HEDIS/Preventive health screenings (target 5 stars in all parts C and D measures, 4 stars in readmissions)

Qualifications

• Strong written and verbal communication skills
• Bi-lingual preferred
• Time-management and organizational skills
• Problem-solving skills - think critically and find potential solutions to problems
• Skills with Windows-based operating systems and EHR
• Skills in operating phones, computers, software, and other IT systems
• Ability to communicate with employees, patients, and other individuals in a professional and courteous manner
• Ability to pay close attention to detail and ensure accuracy of reports and data
• High school education or higher
• At least two years of related work experience preferred
• Licenses and/or certifications: Medical Assistant, LPN, Registered Nurse, or equivalent medical experience