Ambulatory Case Manager

Job Description - Ambulatory Case Manager

Job Description

Ambulatory Case Manager - ( )

Purpose of Position :
The scope of the PHO Ambulatory Case Manager is to manage the PHO covered lives under risk ("PHO Members" or "Members") by reducing acute care episodes. This is accomplished by facilitating high-quality, safe and patient-centered care provided by our PHO physicians. The Ambulatory Case Manager is responsible for the timely facilitation, education and coordination of care in relation to the member’s ambulatory sensitive chronic disease conditions and severity of their illness burden.

Job responsibilities include coordinating care effectively as a team leader, working closely with the interdisciplinary team of Physician Offices to review referrals and plan and implement an individualized care plan that promotes high-quality, safe, patient-centered, and cost-effective care. The ambulatory case manager must assess the member’s care needs utilizing established standards of care and/or approved clinical guidelines.

Hiring Pay Range : $ 0 - $ 0

Thepayrange displayed on each job posting reflects the anticipated range for new hires. A successful candidate’s actual compensation will be determined after taking factors into consideration such as the candidate’s work history, experience, skill set, and education. This is not inclusive of the value of Cape Cod Healthcare’s benefits package (if applicable), which includes among other benefits, healthcare/dental/vision and retirement. For annual salaries this is based on full-time employment.

Description

• Exhibits a commitment to the mission and goals of the organization and demonstrates a respect for working in a collaborative decision-making process by incorporating continuous quality improvement.
• Gathers and analyzes specific criteria and guidelines to track and manage inpatient high risk admissions, avoidable ED visits, readmission and high cost utilization of the PHO members.
• Ensures the appropriate delivery of services through Assessment and Case /Problem Identification, Coordination, Planning, Monitoring and Evaluation.
• Facilitates the delivery of services by establishing relationships with all health care providers, health plans, facilities and community resources insuring appropriate utilization across the continuum of care.
• Communicates in a clear and effective manner with members, their families, caregivers, physicians and other health care personnel.
• Communicates in a clear and effective manner with members of varying educational levels, backgrounds and cognitive levels.
• Shows empathy and compassion in case managing our members; makes every effort to understand the circumstances affecting the member and their health care and vested interest in the wellness of the member.
• Works with the members on realistic goal setting while incorporating socio-cultural ethnic factors, support and facilitate members to move towards achieving their goals.
• Accommodates the member’s preference for mode for patient education and coaching such as telephonic, in-person or video conferencing.
• Initiates an in-person visit with the member based on established case management standards of care and protocols.
• Assess the member’s home environment to identify potential risks and barriers to the health and wellness and makes appropriate referrals as needed.
• Adheres to defined plan of care and adjusts the plan as appropriate based on the member’s status and information collected upon reassessment.
• Collaborates with, and is responsible for, coordination with other disciplines participating in the Plan of Care (i.e. PCP, Specialist, Dietician, VNA, SNF/Rehab personnel, community resources). Participates in multi-disciplinary patient case conferences; evaluates the effectiveness…