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 patients 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.
Other duties and responsibilities:
Demonstrates an understanding of care management, high-risk management, transitions of care, complex and chronic conditions, post-acute care options, and community management standards.
Certifications and Licensures
RN: Registered Nurse MI
Required Education
Education: Associates: BSN is preferred.
Other Information
Education, experience, training and skills:
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.
Physical/mental requirements and typical working conditions:
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.