Care Manager I

About the role

The Care Manager I is an integral member of the office care team. They provide care management and care coordination for patients experiencing transitions of care, undergoing treatment, or dealing with moderate to complex illnesses.

Responsibilities

• Collaborates with members of the health care team and patients to ensure the delivery of quality, efficient, patient-centered, and cost-effective healthcare services.
• Affirms patients in managing their health by providing self-management support and patient education.
• Empowers patients to avoid hospitalization and emergency room visits by implementing targeted interventions in specialty populations.
• Assesses, plans, implements, monitors, and evaluates the delivery of individualized patient care with the goal of optimizing health status.
• Serves as an active member of the office-based care team and supports the identification and referrals of eligible patients for care management support.
• Engages hospitalized patients to facilitate the transition of care and provides support and education to prevent further readmissions.
• Coordinates the care and services of selected member populations across the continuum of care, promoting effective utilization and monitoring of healthcare resources.
• Maintains the ability to utilize guidelines and standards of care for managing chronic diseases.
• Makes "cold calls" and effectively engages patients into the program.
• Identifies common populations and high-volume complex populations within the practice and prioritizes interventions.
• Coordinates and provides patient education for common patient populations within the office.
• Designs individual plans of care for patients based on evidence-based guidelines.
• Fosters a team approach by collaborating and referring patients to supporting members of the care team and ensuring coordination of services.
• Assesses health behaviors and disease-specific risks; identifies a plan of action for patients.
• Affirms clinical compliance with follow-through using reminders, follow-up calls, patient and office education.
• Refers selected patients to determined community resources and coordinates 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 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 the orientation process by having new CM shadow.
• Provides feedback on the CM orientation process.
• Evaluates and manages day-to-day workflow and adjusts 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.
• 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. Implements a plan of coordinated care that supports the individual's goals, strengths, and preferences in collaboration with the Home Based NP and/or primary care physician.

Qualifications

• Bachelor of Science degree in Nursing (BSN) or Associates Degree in Nursing with extensive nursing experience.
• Completion of self-management support training preferred.
• Valid, unrestricted RN license in the State of Michigan; valid CPR certification.
• CCM certification preferred.
• 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.
• Ability to use other software as required while performing the essential functions of the job.
• 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.
• 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.