Care Manager

Hours:

Salaried

Reports to:

Clinical Operations

Utilize Health is an early-stage care management company specializing in populations with complex needs. Our current focus is helping those with neurological diagnoses such as traumatic brain injury, spinal cord injury and stroke.

The Care Manager is responsible for the coordination of care focused on patient transition through the Utilize Health patient journey. The Care Manager conducts care coordination visits in the community and in the member home setting. The Care Manager assumes responsibility for assisting members with navigating the healthcare system, facilitating communication and access with providers and community resources, providing patient and family education that supports self-management and reduces complications & sequelae, and interventions that address social determinates of health.

The Care Manager acts as a patient advocate in supporting factors that impact customer satisfaction and overall health outcomes.

• Member of the Utilize Health multidisciplinary care coordination team, serving as an advocate from patient enrollment through graduation.
• Serve as primary representative of Utilize Health to our members, working under the guidance of the Neuro Nurse and act as an advocate guiding members through their care needs.
• Manage a member caseload through in-person, phone and electronic means of communications and coordination.
• Conduct initial in-person visits with members to complete screenings and identify needs to assist members in making lifestyle adjustments, learn to self-manage their care, and anticipate complications associated with their condition.
• In collaboration with the members, develop an individualized care plan with measurable goals, objectives, and interventions to ensure needs are met.
• Implement interventions as identified in the member’s care plan.
• Ensure timely and appropriate documentation.
• Clearly document all member interactions in the electronic medical record platform, including care plan activities, screenings, visit notes, medical and social history, communications with or on the member’s behalf.
• Perform care coordination activities to include continual monitoring of members’ physical and behavioral health needs, interventions, patient education, and development of an individualized care plan with measurable goals that ensure needs are met.
• Consult with the Nurse on members’ progress and revise care plan as needed to address changes in the member’s condition, lack of progress toward goals, preference changes, and transitions in care settings.
• Help members identify, access, and navigate community services/resources so they are better able to adopt healthy behaviors; help connect the dots in care coordination activities to ensure facilitation is seamless.
• Help coach/educate members on self-care to improve to meet both personal and clinical goals.
• Professionally interact with members’ care providers including primary care, specialists, therapists, counselors, and office staff.
• Schedule provider appointments on behalf of members.
• Accompany members to their appointments when needed.
• Facilitate closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing.
• Improve outcomes by reducing hospital and emergency room admission, closing gaps in care, and actively coordinating care of individuals with a diagnosis of stroke, spinal cord injury or brain injury.
• Demonstrate knowledge of community and care resources.

• Responsible for attending all in-services, continuing education, and annual health requirements.
• Comply with all OSHA and safety policies, practices, and procedures.…