The RN Care Manager works collaboratively as an active member of the Population Health Administration to provide comprehensive, person-centered care management services for patients.
Requirements
- Conduct intake assessments, screenings and obtain necessary consents.
- Develop person-centered care plans with Primary Care Providers and with guidance from supervisor and other clinical experts as needed.
- Provide self-management education and bridge resources/services that are supportive of social and medical needs.
- Support transition planning when patients are admitted/discharged from hospitals or other institutional settings.
- Provide patient consultation in adapting treatment goals, identifying strengths, creating action items and addressing barriers to goals.
- Builds and maintains a full patient panel by actively identifying patients who qualify for program benefits and initiate's outreach.
- Develops outreach and engagement strategies to engage qualified patients.
- Complete referrals for unmet social determinant of health needs
- Educates providers and clinical staff on program services, identifying qualified patients, and patient engagement tactics.
- Work with MAHEC’s Quality Improvement team to improve care management delivery and patient outcomes.
- Ensure required care management data and metrics are documented, tracked, and reported successfully to meet quality standards and guarantee closure of care gaps.
- Collaborate with MAHEC’s clinical departments (Family Medicine, Internal Medicine, Pharmacy, OBGYN, and Psychiatry) and community resource organizations to ensure seamless care coordination/management for the population being served.
- Coordinate and may facilitate integrated Care Team meetings where patient Care Plan is discussed.
- Create a Care Management Crisis Plan and coordinate diversion efforts for patients at risk of admission to an institutional setting.
- Identify system barriers and collaborate to resolve issues with MAHEC departments and with community stakeholders.
- Collaborate with MAHEC’s QI, central billing office (CBO) and audit team to perform regular claim review and education
Benefits
- Generous Paid Time Off
- 401k Matching
- Retirement Plan
- Health Insurance
- Dental Insurance
- Vision Insurance
- Life Insurance
- Disability Insurance
- Malpractice Insurance
