The Care Manager works in collaboration with primary care providers and the patient care teams to identify and proactively manage the needs of patients with high risk or complex medical, behavioral health and/or psychosocial problems through practice, community and home based visits and telephonic support. The Care Manager develops and implements a care management plan based on patient goals, preferences and disease states to promote improved health care outcomes and quality of life. The incumbent in this position serves a central role in linking patients to appropriate community resources, facilitates referral to appropriate care services, supports patient self-management, and communicates with providers in order to reduce barriers to improved health care outcomes. Additionally, this position serves as an integral member of the primary care practice's care team, assesses patients for risk of adverse health outcomes, and measures the impact of care management interventions.
• Conducts condition assessments to identify patients with high risk or complex medical, behavioral health and/or psychosocial problems.
• Conducts assessment of patient needs, preferences, clinical, and psychosocial barriers.
• Creates and analyzes registries for patients at high risk or with chronic diseases.
• Develops and implements population based strategies to close gaps in care by engaging patients in a trusting relationship, thereby enabling effective intervention and support and promoting self-advocacy.
• Monitors patient’s level of activation relative to their health goals over time.
• Identifies resources for patient self-management skills and advocates for patients to ensure access and timely service delivery across the continuum of care.
• Develops and implements care plans based on the patient's goals, strengths and barriers that promote improved health care outcomes and quality of life.
• Provides culturally competent interventions based on patient assessment and identified cultural needs, including patient and family education, assessment of caregiver burdens, and ensuring appropriate language/translation access.
• Identifies barriers to a successful care management path and makes recommendations to management for overcoming these barriers
• Provides care coordination with Primary/Specialty Medical care, acute and outpatient medical, mental health and substance abuse services, and other care managers involved in supporting the individual.
• Provides comprehensive transitional care involving coordination of care and services post critical events, such as emergency department use, hospital inpatient admission and discharge or skilled nursing facility admission and discharge.
• Provides crisis intervention planning addressing events such as emergency department visits or inpatient admissions or other crisis events to ensure planned crisis interventions are effective and to make necessary modifications of the Plan of Care or need for additional support services.
• Conducts medication reconciliation as appropriate and communicate needs for adjustments to care team/provider.
• Conducts patient progress no less than on a quarterly basis.
• Modifies goals and care management interventions as appropriate to the needs/progress of the individual.
• Shares information between team members and other care providers.
• Handles confidential information in accordance with HIPPA, state and federal privacy and confidentiality rules.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
• Interacts effectively with physicians and other members of the health care team
• Bachelor’s degree in Nursing with current NYS licensure, and a minimum of 5 years of clinical nursing experience. Care Management experience preferred.
• Minimum 3 years community health experience.
• Knowledge of community resources required
• Working knowledge of health care and health insurance provisions in a variety of service settings.
• Excellent communication skills and ability to form collaborative partnerships across all service settings
• Good listening skills
• Sound reasoning and problem solving skills
• Ability to assimilate new information and technologies into daily work
• Strong computer skills: Competent in Microsoft Office products (Word, Excel, Outlook, PowerPoint)
• Ability to interact with individuals with diverse cultural and religious customs
• Must have a NYS driver’s license and car for community travel.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer
Lifetime Health Medical Group - 16 months ago
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