Clinical Manager-MSH-12791-001

About the role

The Clinical Manager oversees the continuity of patient care in the ALIGN-CARE Geriatric Surgery Co-Management program. Patients are 65 years or older, frail, community-based, and considering surgery. The program starts with approximately 50 patients and grows to 200-250 by the second year.

Responsibilities

• Assess patients for surgical risks and provide care plans to optimize their health before surgery.
• Lead initial assessments of patient candidates and follow-up tracking and phone calls for education and counseling pre-, peri-, and post-operatively.
• Follow up with patients via telephone and transitional care management workflow after discharge from the hospital, aiming to reduce unnecessary return to the emergency room or hospitalization.
• Access both Mount Sinai Hospital and Mount Sinai Morningside hospital domains for telephonic and video visit care, and sometimes in-person care (outpatient clinic).
• Work alongside interdisciplinary team members (administrative associate, nurse practitioner, care coordinator, and social worker) within the Brookdale Department of Geriatric and Palliative Care Medicine.
• Report to the Geriatrician program director (Dr. Stephanie Chow) and collaborate with surgical teams (surgeon, physician assistant, nurse practitioner, administrative assistants) and extended care team (physical therapist, visiting nurses, pharmacists, etc).
• Track patients throughout the program (Pre-, Peri-, Post-operatively) in a secure patient database, document clinical encounters in EpicCare EMR, provide patient and caregiver instruction and coaching, and correspond with relevant teams as needed.
• Evaluate and develop the clinical program by overseeing the collection, compilation, and analysis of clinical program activity data to evaluate clinical performance and competence. Generate biweekly and monthly reports of program progress and performance, and present reports to stakeholders and team members as needed.

Qualifications

• Bachelor’s degree in a health-related field, such as Nursing, PA, Physiology (Master’s preferred), with current licensure.
• Nursing or Physician Assistant experience preferred.
• Master’s in Exercise Physiology preferred if the position is utilized in this particular clinical area.
• 5+ years of clinical experience with 2 years of management and supervisory experience preferred.