United States onlyThe primary duties of this position involve facilitation of continuity of care across the healthcare continuum. This role acts as a navigator and advocate for better health outcomes for patients served by the primary care physician. The Care Manager is responsible for managing high risk patients with multiple comorbidities or at high risk for hospital admission or readmission. This will include developing and monitoring health promotion, disease management, care coordination and utilization management. The Care manager will develop care plans in conjunction with the care team to implement interventions that assist moving the patient toward optimal health. The Care manager will facilitate care transitions after a hospital admission to ensure the patient has a seamless experience and well coordinated care.
Care Management - Work with all clinical teams as a resource on care management
- Identify targeted patient populations that would benefit from care management.
- Pre-visit planning workflow to ensure care completion prior to visit whenever possible
- Use of efficient, accurate point of care reminders for evidence based care
- Coordinates patient care services for selected patients across the continuum of care through collaboration with the patient and family and health care providers in achieving optimal patient outcomes
- Communicate with patients after hospitalizations to schedule appointments, assist with medication education, review after visit summary and provide the patient with a point of contact.
- Collaborate with the Care Team and follow up appropriately to ensure smooth transition of care for patients treated in a facility (inpatient or emergency department), by a specialty physicians, or by another health care provider
- Involve patients in activities to improve their health (patient engagement);
- Educates patients about self-management tasks they can undertake to gain greater control of their health status.
- Conducts health teaching and health counseling to patients and/or their families.
- Identify barriers preventing patients from achieving optimal health, problem solve and plan with the Care Team and outside resources to overcome.
Clinical quality and performance
- Works closely with providers as well as clinical staff to assure clinical quality is an ongoing priority in all phases of patient care.
- Participates in clinical quality activities and facilitate implementation of clinical best practices.
- Network/collaborate with professional colleagues and outside community agencies to develop best practices.
- Coordinate with physician leadership to develop strategies for the high risk patient population to coordinate patient care from office to hospital to home.
- Monitors utilization of resources and collaborates with the patient and care team to promote efficient and appropriate use.
- Provides leadership in the development of office workflows, collaborating with physicians on the development of care standards with preventative services and chronic disease management.
- Leads health care team by influence and role modeling integrated effective nursing practices, excellent customer service, innovation and providing outstanding support for the physician practice.
- Ensure safe practices and report any concerns
Provide the highest level of customer service to achieve the goal of “putting patient’s first”.
- Promote excellence in healthcare delivery to the patient and/or patient family. Identify and facilitate implementation of clinical best practices.
- Engages co-workers and patients in a positive, respectful manner
- Shows respect and sensitivity for differences among co-workers and patients
- Facilitate seamless patient experience by coordinating care with the care team, patient and family.
Information Technology:
- Ensure complete and accurate documentation in the medical record
- Effectively use all electronic tools to deliver evidenced based care
- Design effective workflows using population management software, the electronic medical record and registries
- Collect and monitor data related to outcomes.
- Participate in performance improvement projects to leverage the electronic medical record
All other duties as assigned.
KNOWLEDGE AND SKILLS:
Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position.
EDUCATION: Registered Nurse
YEARS OF EXPERIENCE: Minimum of 3 years experience
REQUIRED SKILLS AND KNOWLEDGE:
Autonomous
Excellent problem solving and critical thinking skills
Ability to prioritize work, and manage multiple demands
Knowledge of basic computer functions
Ability to communicate effectively with others, both written and verbally
Ability to work both with and for the team
Ability to show respect and sensitivity to cultural differences in both employees and patients
Knowledge and support of organization’s goals and values
LICENSES & CERTIFICATIONS:
Must be current Registered Nurse Licensed in state of Ohio
