Care Manager I

About the role

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.

Responsibilities

• 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.
• Participates in the outreach and engagement of patients that are hospitalized to assist with the transition of care and provides support and education to avoid further readmissions.
• Carefully 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.
• 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.
• Affirms 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.
• Works with patients and providers to customize services that will best meet the needs of the patient and work within their benefits.
• Researches and facilitates services for patients outside of their benefits while utilizing community services and resources.
• Assists in orientation process by having new CM shadow.
• Provides feedback on the CM orientation process.
• Evaluates and manages day to day workflow and adjust as needed to increase efficiencies.
• Attends required meetings and training, and participates in committees as requested.
• Assists with special projects and performs other duties as assigned and works within the scope of RN licensure.
• In addition, for those working on the Home Based Care Team: Performs assessments of the home and social determinants of health for individuals aged 65 or older. In collaboration with the Home Based NP and/or primary care physician the care manager works to implement a plan of coordinated care that supports the individual’s goals, strengths and preferences.

  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.

  Skills

  • Knowledge of patient care procedures and organizational policies related to position responsibilities.
  • Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education.
  • Excellent assessment and triage skills (per specialty population expectations).
  • Understands chronic disease management strategies and is able to implement appropriate protocols and guidelines.
  • Proficient/knowledgeable in medical terminology.
  • Proficient in operating a standard desktop and Windows-based computer system, including but not limited to, electronic medical records and other care management and/or clinical IS systems, email, e-learning, intranet, Microsoft Word and Excel, and computer navigation needed to complete the tasks of clinical care and performance reporting.
  • Excellent communication skills in both written and verbal forms, including proper phone etiquette.
  • Ability to speak before groups of people.
  • Ability to work autonomously and collaboratively in a team-oriented environment; courteous and friendly demeanor.
  • Ability to work effectively with various levels of organizational members and diverse populations including IHA staff, providers, provider leadership, patients, family members, insurance carriers, vendors, external customers and community groups.
  • Good organizational and time management skills to effectively juggle multiple priorities and time constraints.
  • Ability to exercise sound judgement and problem-solving skills.
  • Demonstrated skills with influencing and negotiating individual and group decision-making.
  • Ability to handle patient and organizational information in a confidential manner.
  • Knowledge of the compliance and quality aspects of clinical care and patient privacy and best practices in medical office operations.
  • Ability to travel to other office/practice sites and meeting and training locations.
  • Successful completion of IHA competency-based program within introductory and training period.

  Requirements

  • Physical Activity: Physical activity that often requires keyboarding, phone work and charting. Physical activity that often requires extensive time working on a computer. Physical activity that often requires handling and lifting patients walking, standing, bending, stooping, reaching, climbing, kneeling and/or twisting. Physical activity that often requires lifting, pushing and/or pulling up to 20 pounds.
  • Specific Vision Abilities: Specific vision abilities required include close vision, depth perception, peripheral vision and the ability to adjust and focus. Manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment. Must hear and speak well enough to conduct business over the telephone or face to face for long periods of time in English.
  • Environmental Expectations: This job operates in a medical facility and requires regular walking to various locations around the hospital/clinic. Employees will be working where there is patient care equipment. Hazardous materials, including blood borne pathogens and bodily fluids are also present. Exposure to sharps, x-rays, patients' conditions and some unpleasant sights, smells and contagious diseases is possible. This position requires significant interaction with people (many of whom are scared, hurt and/or ill) which can be stressful and result in competing priorities.