Clinical Care Manager

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?

The Clinical Care Manager is responsible for promoting organizational values of patient and visitor satisfaction by demonstrating

courtesy and respect for families, visitors and other employees. Collaborates with practices and actively provides clinical

support to "high-risk" patient populations for multiple practices - in all age groups ranging from young adulthood through

geriatrics. Demonstrates competence in the assessment, treatment and care of patients serviced. Will include

travel, telephone or telehealth encounters as appropriate to patient needs.

• Designs and implements care management support activities for high risk patients with chronic diseases and high medical service utilization.
• Collaborates with physician and practice staff in identifying appropriate patients for care management utilizing established criteria. Collaborates with the patient and provider to establish and implement a care management plan using evidence based guidelines. Develops patient objectives and measures progress according to standards of care.
• Triages patient telephone calls and provides consultation regarding ongoing symptom management resulting from treatment and disease, analysis of intervention regarding diagnostic work-up, assessing and managing acute emergencies, managing family concerns as needed, liaison activities with affiliated physicians, nurses, pharmacists and emergency rooms.
• Initiates appropriate evaluation and management of emergency situations.
• Coordinates patient’s management/treatment plan throughout the institution.
• Instructs patient/family regarding medications and treatments. Educates patients regarding health and illness prevention.
• Recommends community resources to meet patient and family needs. Develops patient education programs.
• Creates, uses, and maintains patient-specific care management tracking system that identifies/ reports on patients who will benefit from care management services, the subsequent patient progress, and associated interventions.
• Supports QA and maintenance efforts for patient registries and quality reporting. Works with the Clinical Analyst to summarize and analyze data from registries
• Promotes patient self-management and empowers patient and families to achieve optimal health outcomes. Assists patient to identify and/ or develop and utilize their support systems.
• Evaluates the effectiveness of care management plan in meeting established care goals and revises the plan as needed to reflect changing needs, issues and goals.
• Prepares and maintains appropriate documentation as required.
• Collaborates with all members of the health care team to resolve patient health, social or behavioral health needs.
• Provides monitoring and continuity of care between physician visits. Maintains and reviews patient records, charts and other pertinent information.
• Performs duties in accordance with Penn Medicine and entity values, policies, and procedures
• Other duties as assigned to support the unit, department, entity, and health system organization

• Associates Degree in NLN-approved school of nursing required
• Bachelors Degree in nursing and 1+ years prior nursing experience in internal/family medicine and care management experience preferred

• Active PA or NJ RN license based on position location. Dual (NJ & PA) RN licensure required within 3 months of Hire required

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission.

Together we will…