Care Manager I - Hybrid

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 high-quality, efficient, patient-centered, and cost-effective healthcare services.
• Aids patients at risk for chronic conditions in minimizing these risks through self-management support and patient education.
• Empowers patients to manage their health and avoids hospitalizations and emergency room visits for specialty populations by ensuring proper triaging and care delivery according to established protocols.
• Assesses, plans, implements, monitors, and evaluates individualized patient care to optimize health status.
• Serves as an active member of the office-based care team, supporting the identification and referrals of eligible patients for care management support.
• Engages hospitalized patients to facilitate the transition of care and educates them to avoid further readmissions.
• Coordinates care and services for selected member populations across the continuum of care, promoting effective utilization and monitoring of healthcare resources, and collaborating with all members of the healthcare team to achieve optimal clinical and resource outcomes.
• Maintains the ability to utilize guidelines and standards of care for managing chronic diseases.
• Makes "cold calls" to engage patients in the program and prioritize interventions for common patient populations.
• Refers selected patients to community resources and coordinates with these resources.
• Provides patient-specific feedback to providers and clinical team.
• Facilitates services for patients outside of their benefits while utilizing community services and resources.
• Assists in the orientation process by having new Care Managers shadow and provides feedback on the orientation process.
• Evaluates and manages day-to-day workflow to increase efficiencies.
• Attends required meetings and training, participates in committees as requested, and assists with special projects.
• Performs assessments of the home and social determinants of health for individuals aged 65 or older, implementing 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 a 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).
• Understanding of chronic disease management strategies and ability 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.