Summary
Provides care management and care coordination for adult and pediatric patients with complex illness in the primary care setting under minimal supervision. Works with both moderate and high risk patients to optimize control of chronic conditions and prevent/minimize long term complications. Coordinates care across settings and helps patient/families understand health care options. In partnership with the primary care practice leadership team, the Care Manager leads care management within the team. The Case Manager (CM) accomplishes this through process improvement, workflow redesign, providing assistance with training, and delegating to other members of the team. The CM serves in an expanded health care role to collaborate with specialists, members of the health care team, and patients/families ensuring the delivery of quality, efficient, and cost-effective health care services. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient�s health status. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care.
Responsibilities
(25%)* Collaborates with primary care provider (PCP), patient, and members of the health care team, including continuum of care settings and community. Responsible for developing a comprehensive individualized plan of care and targeted interventions. Continually monitors patient/family response to plan of care, and revises the care plan as indicated.
(20%)* Identifies the targeted high-risk population within practice site(s) per PCP referral, risk stratification, and patient lists. Includes patients with repeated social and/or health crises.
(20%)* Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
(15%)* Assesses over time the health care, educational, and psycho-social needs of the patient/family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.
(10%)* Provides patient self-management support with a focus on empowering the patient/family to build capacity for self- care.
(10%)* Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.
Certifications and Licensures
RN: Registered Nurse MI
Required Education
Education: Associates: BSN is preferred.
Other Information
Demonstrates an understanding of care management, high-risk management, transitions of care, complex and chronic conditions, post-acute care options, and community management standards.
Provides care management and coordination within the timeframe provided with the CM Program guidelines and the care plans. Conducts clinical assessments. Develops, monitors, and updates a person-centered care plan. Actively secures the necessary authorizations for the services that are the responsibility of the organization to ensure the member's timely access to the services identified in the person-centered care plan.
Able to adhere to communicated care management productivity metrics, including caseload, engagement volume, and time to closure. Also adheres to quality standards for care management per policy, including appropriate cases opened, comprehensive documentation, actionable care plans, and appropriate cases closed in a timely fashion.
Ensures the member receives the full scope of care coordination services, including comprehensive assessment completion as required.
Coordinates across the interdisciplinary care team, including transitions of care to ensure safety and quality of clinical care. Demonstrates participation in multidisciplinary team rounds, as appropriate, to address utilization/resources and progression of care issues. Assists in developing and implementing an improvement plan to address issues. Implements goals and objectives that support overall strategic plans of the organization. Conducts incident reporting as required.
Identifies gaps in care and takes action as necessary to close gaps in care. Outreaches to patients to engage in care management, coordination, and education. Offers and links patients, as appropriate, to health education, disease management, and wellness/prevention coaching. Educates members about available resources and services (e.g., value-added benefits) and assists the member in accessing those resources and services, if not already involved.
Educates the client, family or caregivers, and members of the health care delivery team about treatment options, community resources, insurance benefits, and/or psychosocial concerns so that timely decisions can be made. Maintains objectivity in decision-making and utilizes facts to support decisions.
Communicates and exchanges information with providers (e.g., PCP, specialists, labs, imaging facilities), and other care coordination entities as appropriate. Assists with bi-directional communication between state-driven coordination entities (if applicable), specialists, pharmacies, labs, and imaging facilities as needed in order to facilitate timely exchange of information.
Facilitates clinical handoffs and participates in discharge planning activities with the inpatient facility to support a safe discharge placement and to prevent unplanned or unnecessary readmissions, ED visits, and adverse outcomes. Ensures member access to post discharge services as specified in the discharge and transition plan.
Demonstrates an understanding of funding resources, services, clinical standards, and outcomes. Has an understanding of managed care trends, payer regulations, reimbursement, and the effect of utilization on the different methods of reimbursement.
Demonstrates the ability to evaluate utilization/resource/clinical care management data to identify trends, develop action plans, and program modification for improved outcomes.
Equivalent Experience And Other Comments (Education)
2 years of case management experience is preferred.
Three years of experience with adult medicine/pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting, within the past five years.
Knowledge of chronic conditions, evidence based guidelines, prevention, wellness, health risk assessment, and patient education.
Health Plan/Payer Experience Is Preferred.
Critical thinking and problem solving skills and ability to analyze complex data sets.
Ability to manage complex clinical issues utilizing assessment skills and protocols Excellent assessment and triage skills.
Ability to implement evidence base interventions and protocols for chronic conditions Demonstrates excellent communication--both verbal and written; dependable, self directed.
Experience with managed care data systems and reporting.
Must be able to type documentation concurrently during conversations. It is required of the care manager to document concurrently in the care manager platform as coordinating care with patients, providers, or other members of the care team.
Proficiency in various word processing, spreadsheet, graphic and database programs, including Microsoft Word, Excel, Access, PowerPoint, Outlook, etc.
Other Comments
Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death.
Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position.
Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description.
Overall vision and hearing is necessary with or without assisted device(s).
Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching.
Some exposure to blood borne pathogens and other potentially infectious material. Must follow MyMichigan Health bloodborne pathogen and TB testing as required.
Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.
Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis.
Physical Demand Level:Light. Must be able to occasionally (0-33% of the workday) lift or carry 11-20 lbs., frequently (34-66% of the workday) 10 lbs. and or Walk/Stand/Push/Pull of Arm/Leg controls.
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