Community Care Manager LPN/RN

Job Posting

Schedule: Monday-Friday

Pay Range: $30-40 per hour, dependent on experience and license

Summary Of Job Duties

The Community Based Care Manager is responsible for performing the physical assessment, triage, care coordination, documentation, communication, and ensuring timely response to patient calls and cases for a panel of home and community based high acuity Traditional Medicare and Medicare Advantage Plan patients in the Complex Care Management Program.

Complex Care Management services provide a mix of in home and in person clinic visits with patient (and/or HIPAA Representative), as well as telephonic visits in between appointments each month. The Community Care Manager facilitates shared decision making and ongoing goals of care discussions with the patient and family, collaborates with other members of the Care Management team, clinical staff, physician, or other qualified health care professionals to provide high quality care with meaningful impact. Through this collaboration, a comprehensive care plan is established, documented in the Electronic Health Record (EHR), implemented, and is reviewed or revised during each subsequent encounter.

A comprehensive care plan includes an electronic summary of the patient's physical, mental, cognitive, psychosocial, functional, environmental, and social assessments. It contains a record of all patient goals, recommended preventive care services, medication reconciliation with review of adherence and potential interactions and oversight of patient self-management of medications, an inventory of clinicians, resources, and supports specific to the patient; including how the services of agencies and/or specialists unconnected to the designated physician's practice can be coordinated. It includes ensuring that ER and hospital clinical documents, consult notes and other records of care are current and available on the chart for review as needed.

The Community Care Manager is responsible for ensuring that care and services are delivered appropriately and timely in the home or other community setting to his/her panel of patients. Under the direction of and collaboration with the primary care provider and leadership, the Community Care Manager identifies the appropriate level of care needed by each patient in his/her care and carries out in home clinical services including, but not limited to injections, obtaining specimen for laboratory evaluation, and giving IV fluids as ordered by the Primary Care Provider. He/she provides ongoing education to help patients meet their goals and facilitates ongoing goals of care conversations.

The Community Care Manager coordinates efforts with the Quality Department to ensure that each patient is accurately assessed, and that Annual Wellness Visits are completed quality measures and gaps are closed. He/she accurately updates patient's problems list, diagnoses, health conditions, mediations list and Care Team and brings additional medical concerns to the Primary Care Provider.

Essential Job Functions

• The Community Care Manager follows and maintains a panel of high acuity Complex Care Management patients in the community setting as assigned by leadership.
• Is responsible to coordinate and communicate with providers, staff, and patient's Care Team members (including specialists, Case Managers and patient's family and/or representative) regarding the patient's specific and appropriate acuity level of care needed, as determined by their chronic conditions, acute care events and social/living needs.
• Ensures that the care patients receive is efficient, thorough, timely and is properly documented to help patients avoid ER and urgent care visits, hospital admissions and readmissions. Assists in ensuring the best quality of life possible for each patient in their care.
• Works with the leadership to identify specific patient social and preventative care needs. Facilitates resolutions, when possible, with resources throughout an assigned geographic area.
• Provides regular reporting of activities and statistical status of the CCM patients in his/her care to leadership and the Primary Care Provider as directed.
• The Community Care Manager helps to fill in for other Care Pod staff as needed.
• Participates in department rotating "on-call" schedule determined by leadership.
• Participates in pertinent meetings, workshops, seminars, and related forums as directed.
• Maintains confidentiality and follows HIPAA and OSHA guidelines.
• Maintains current Licensure in the State of employment.