CTO Transition of Care LPN Care Manager

About the Job

General Summary of Position

Serves as a member of the interdisciplinary care management team capable of furnishing an array of care coordination services to Medicare FFS beneficiaries attributed to practices that the Care transformation Organization (CTO) supports;
Responsible for the care coordination of Medicare FFS beneficiaries attributed to a medical practice(s);
Serves as the liaison between the medical practice and the CTO's interdisciplinary care management team.

• Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
• In collaboration with the interdisciplinary care team acts as primary care team agent for the episodic care needs and coordination of care for a panel of attributed Medicare beneficiaries following discharge by ensuring the following:
  Ensures attributed beneficiaries have timely access to care (same day or next day access to the patient's own practitioner and/or care team for urgent care or transition management);
  Assists patients with scheduling appointments with providers including annual wellness visits. Review of Discharge instructions and Medication Reconciliation
• Attributed beneficiaries receive a follow up interaction from the TOC Care manager coordinator within 2 business days for hospital discharge and within one week for Emergency Department (ED) discharges;
  Coordinates referral management for attributed beneficiaries seeking care from high-volume and/or high-cost specialists as well as EDs and hospitals;
  Facilitates connection to services for patients who may benefit from behavioral health services including: patients with serious mental illness patients with substance use disorders' patients with depression anxiety or other mental health conditions patients with behavioral and social risk factors and BH issues patients with multiple co-morbidities and BH issues; elevates patients requiring longitudinal / ongoing care management needs following discharge to the CTO Lead Care manager MDPCP Social needs teams and or MDPCP Amb pharmacist where appropriate
• Completes general assessment for barriers or needs including any Social Determinants of Health (SDoH) and makes referrals as appropriate
• Assesses plans implements monitors and evaluates options and services to meet health needs of attributed beneficiaries up to 30days following In patient discharge or Emergency room visit . Manages a caseload in compliance with contractual obligations and the MD Primary Care Program (MDPCP) standards.
• Monitors and evaluates effectiveness of care plan and modifies plan as needed. Supports member access to appropriate quality and cost-effective care. Coordinates with internal and external resources to meet identified needs of the member's care plan and collaborates with providers
• Acts as a liaison and member advocate between the member/family physician and facilities/agencies. Provides clinical consultation to physicians professional staff and other teams members/supervisors to provide optimal quality patient care and effective operations.
• Ensures members are engaging with their PCP to complete their care management treatment plan or preventive care services.
• Ensures daily telephonic patient communication to help to close gaps in care and provide up-to-date healthcare information helping to facilitate the members understanding of his/her health status using available reports including quality m page and HIE CRISP to ensure relevant medical history/encounter are accessible in EMR.
• Facilitates ongoing communication amongst practice and care team by participating in huddles hosting regular conference calls in-person meetings or coordinating regular email updates to ensure alignment of activity discuss new developments and exchange information.
• Participates in meetings and on committees and represents the department and hospital in community outreach efforts.
• Participates in multi-disciplinary quality and service improvement teams.

• Associate's degree…