RN Care Manager, Population Health

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* JOB SUMMARY:

** The RN 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
* Medication management and adherence support
* Risk stratification
* Population management
* Coordination of care transitions
* Care Navigation and referrals

This is a bilingual position and candidates with Spanish and English fluency are encouraged to apply.

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:
*** 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
* 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:
** Effectively and respectably communicate with other individuals, whether it be a colleague, patient, or patient’s family member and appropriately enumerate information in a manner easily understood by all parties. We do this to foster a culture of understanding between all parties, especially in complex and difficult situations, to ultimately provide the best care possible to our patients and their families.
* ** Decision Making** :
Ability to make the most appropriate decision in a given situation and then taking the next steps to ensure…