Care Manager I

Position Description

The Care Manager I 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

• Collaborates with members of the health care team and patient to ensure the delivery of quality, efficient, patient centered, and cost effective healthcare services.
• Affirms patients to manage their health.
• Empowers patients to manage their health.
• 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.
• Assesses, plans, implements, monitors, and evaluates delivery of individualized patient care with the goal of optimizing the patient’s health status.
• 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.
• 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.
• Maintains the ability to utilize guidelines and standards of care for management of chronic diseases.
• Makes “cold calls” and engages patients into the program effectively.
• Identifies common populations/high volume complex populations within the practice and prioritizes and directs interventions.

Clinical Responsibilities

• Coordinates and provides patient education for common patient populations within the office.
• Designs individual plan of care for patients based on evidence-based guidelines.
• 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.
• Assesses health behavior and disease-specific risks; identifies a plan of action for patients.
• Assures clinical compliance with follow through utilizing reminders, follow-up calls, patient and office education.
• Refers selected patients to determined community resources and coordinate with these resources.
• Provides patient-specific feedback to providers and clinical team.
• Provides face-to-face and telephone interactions with patient population.
• 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.

Organizational Expectations

• Creates a positive, professional, service-oriented work environment for staff, patients and family members by supporting the mission and values of Trinity Health Medical Group.
• Works effectively as a member of the Patient Care team.
• Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.
• Successfully completes all relevant organizational training and adheres to Trinity Health Medical Group standard of care as outlined in the Trinity Health Code of Conduct.
• Maintains knowledge of and complies with Trinity Health Medical Group standards, policies and procedures.
• Maintains strict confidentiality in compliance with Trinity Health Medical Group and HIPAA guidelines.
• Serves as a role model by demonstrating exceptional ability and willingness to take on new and additional responsibilities.
• Embraces new ideas and respects cultural differences.
• Uses resources efficiently.

Essential Qualifications

• Education: Bachelor of Science degree in Nursing (BSN) or Associates Degree in Nursing with extensive nursing experience. Completion of self-management support training preferred.
• Credentials/Licenses: Valid, unrestricted RN license in the State of Michigan; valid CPR certification. CCM certification preferred.
• Experience: 3-5 years of experience with primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical, within the past five years. Care management experience preferred. Experience as participant in continuous quality improvement preferred.