Collaborative Care Manager

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* JOB SUMMARY:

** The Care Manager works collaboratively as an active member of the Population Health Administration as part of an interprofessional primary care team to provide comprehensive, person-centered care management services for patients that include:
Patient education Care Managers will support patients with outreach, scheduled care management and triage response as needed. This role will systematically and continuously collect and assess data related to patient health status to develop, execute, and evaluate the plan of care.

Required care management activities also include care coordination, health promotion, family support, and referrals to necessary resources and supports. These functions may be performed throughout WNC in community-based settings, during home visits if applicable, and in MAHEC clinics and remotely. The Care Manager will collaborate with Complex Care Managers and Tailored Care Managers, Extenders (Peer Support Specialists, Community Health Workers), Care Navigators, MAHEC clinical teams, community partners, and other regional and state stakeholders.

At times the role may also cross over to Tailored Care Management and support patient overflow.
** SPECIFIC RESPONSIBILITIES:
** Provide self-management education and bridge resources/services that are supportive of social and medical needs.  patients who qualify for program benefits and Work with MAHEC’s Quality Improvement team to improve care management delivery and patient outcomes. Collaborate with MAHEC’s QI, central billing office (CBO) and audit team to perform regular claim review and education
* This role description is a general description of the essential job functions.  It is not intended to describe all the duties the Care Manager may perform.
*** KEY

COMPETENCIES:

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* ** Communication Skills
** Ability to make the most appropriate decision in a given situation and then taking the next steps to ensure appropriate and timely completion. This requires conflict resolution skills, critical thinking skills, confidence in your ability to make the right decision in most situations. This also includes ability to prioritize your workday appropriately to ensure the most important tasks are completed on time.
** Health Care Knowledge
** Having the drive to keep yourself abreast and up to date on the new breakthroughs in your area of expertise and communicating them to the rest of the team, as appropriate.  This also includes keeping up with your licensure and yearly training requirements within your area expertise along with MAHEC’s organizational training. Finally, the ability to apply the depth of knowledge maintained and gained through this process in real life scenarios as appropriate.
** Interpersonal Skills
** Showing the ability to meet difficult situations with grace, professionalism, and understanding. Within your area of expertise, showing respect and showing empathy where appropriate with your colleagues, patients, and their family at all times, even when its most difficult to do so. This is done, in part, by effective listening, being your authentic self, showing responsibility and dependability, and being patient with others.

Adherence to MAHEC’s founding principles and incorporating them every day. This includes, among others, having integrity and accountability, reverence for other cultures and equitable practices, ability to manage change, and displaying a clear understanding of organizational dynamics. Doing these things creates a culture where people want to do the best for each other and gives personal ownership towards the goal of helping people in their time of need.

Having an analytical mind and ability to work autonomously to solve complex problems that may arise. The wherewithal to think logically through a difficult problem and come to an appropriate resolution for a given issue. This helps to drive continuous improvement by thinking through where we can improve in a novel way. Measures success by understanding where we are currently and where we want to go and then applying those new ideas to affect positive change.
* * COMPUTER
* * Must be competent with virtual (email, Webex, Zoom, Microsoft TEAMS…