Chronic Care Manager

• Collaborates with physicians, providers, and practice staff in identifying appropriate patients for care management.

• Develops relationships with patients as an integral member of the team.

• Provides follow-up management with patients to ensure compliance with their individual care plan.

• Maintains availability to provide telephone advice per protocol, and handles urgent and emergency calls during working hours.

• Anticipates the needs of the patient population, seeing that necessary documentation and pre-visit planning is completed or requested before patient visit.

• Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence.

• Determines and coordinates appropriate referrals as needed.

• Works with patients and patient’s care team to coordinate change readiness, needs assessment and to develop an individualized treatment care plan.

• Collaborates with the patient, physician, and other care team members in assessing the patient’s progress toward individual health care goals.

• Maintains accessible, consistent documentation of patient self-management measures, and reporting progress toward goals.

• Assists patients in setting SMART goals for self-management, teaching them how to do self-management tasks, and reports abnormal findings to their physician team.

• Assesses barriers when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments.

• Participates in regular team meetings and peer review activities.

• Promotes collaborative teamwork and is able to work with peers in a team situation.

• Collaborates with payer Case Managers for additional services when appropriate.

• Maintains a list of medical supply and community resources available to patients and maintains collegial relationships with the entities used most frequently.

• Makes recommendations for policies/procedures to ensure that preventive services are offered in a timely manner to all who qualify.

• Provides follow-up in the transitions of care from various settings (hospital or skilled nursing facility discharges and emergency room visits).

• Coordinates disease registry activities.

• Participates in departmental and organizational committees as applicable.

Qualification

Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this job.

Knowledge, education and/or

Experience

The Care Manager must have knowledge of the Patient-Centered Medical Home model/mission as well as knowledge of insurance industry practices and requirement. He/she must have an understanding of chronic disease and preventive care measures. Must have a bachelor’s degree in health care administration, health informatics, or a related field and hold licensure as a Licensed Practical Nurse, or an incumbent holding licensure as a Licensed Practical Nurse and having significant experience in chronic care may be considered. Licensure as a Registered Nurse is preferred. Experience working with patients with mental health issues is preferred.