Reporting to the Vice President of Clinical Operations, the Care Manager will work as an embedded member of the health care team in an assigned location collaborating with site physicians and the Associate Medical Director. He/She will be responsible for facilitating collaboration, communication, and care coordination with all members of the healthcare team to support the patient across the health care continumim. He/She will also be responsible to assess, plan, implement and evaluate comprehensive, coordinated health services for the high risk identified patient population to support their achievement of the highest level of self-mangement. This position will also be responsible for working with the VPCO/CMO to help design, develop, and spread the care management model across Core's Patient Centered Medical Homes .
- 3 to 5 years Care Management, Care Coordination, or Case Management experience
- Bachelor's degree in related field or equivalent experience
- Registered Nurse - N.H. State or Valid Nursing License in another Compact State
1. Serves as the liaison with assigned patients, families, to physicians and clinical staff involved in the care of the patients. Advocates for the patient and families, responds to and facilitates resolution of patient questions and concerns. Provides or arranges needed patient education regarding specific health care skills and general disease concepts.
2. Conducts comprehensive clinical assessments that include the age-specific, medical, behavioral, pharmacy and social needs of each assigned patient. Shares this informaton with the healthcare team and with the patients. Uses this information to develop and maintain a customized, patient-specifc care plan incorporating the patient and family in the development of the plan.
3. Partners with patients and families on self management support including:
a. Sets short and long-term goals for self-management of chronic disease to include acute exacerbation mangement.
b. Performs reassement in patient progress toward goals, assesses barriers and alters plan of care as appropriate.
4. May assist other members of the health care team with identifying patients overdue for visits, labs, in need of referrals or addmitted to ED, inpatient, sub-acute facilities or VNA and arranges for follow up as appropriate
5. May assist other members of the health care team to optimize patient experience with provider visits by assisting with pre-chart review for required preventative health maintenance needs, chronic disease interventions, necessary forms etc.
6. Utilizes disease registry database, updating as necessary, monitoring quality reporting from registry.
7. Works with Practice manager to insure that all appropriate members of the health care team are regularly monitoring registries for gaps in care as part of pre and post visit planning.
8. Participates in quality improvement projects aimed to improve patient-population outcomes and associated processes.
9. Works closely with VPCO/CMO and their designees to help design plan for roll-out of this function across the patient centered medical homes.
10. Works with EHRi to develop tools for efficient, effective care management and care plans. Resource to clinical staff and providers for care coordination issues.