Care Manager: POP HEALTH SO (PHSO)
About the Job
The Care Manager is a member of a dynamic care management team responsible for achieving the highest levels of care transitions for a target population of the Memorial Healthcare System and Memorial Health Network. The Care Manager is responsible for improving the delivery of health care across the care continuum supporting positive outcomes, quality of care, and enhancing the patient experience.
• Develops patient care plans based upon the assessment of the patients' care needs and provides ongoing monitoring of assigned patient case load through the duration of the program. Maintains client records by reviewing case notes, logging events and progress.
• Monitors cases by verifying patients' attendance to scheduled appointments; observing and evaluating treatments and responses; advocating for needed services and entitlements; obtaining additional resources; intervening in crises; providing personal support.
• Determines patients' requirements by completing intake assessments; determining the need for therapeutic medical, psycho-social, and psychiatric evaluations; reviewing therapist evaluations, treatment objectives, and plans.
• Provides ongoing follow-up support and education to patients and caregivers, either in-person or telephonically, until transitioning the patient back to their primary care provider or ambulatory care manager for long-term support. Ensures that assigned patients who are discharged from any inpatient institutions are followed up by their primary care providers within 7 days. Communicates the patient plan of care with the physician, patient and care team members. Remains aware of patient needs and changes in patient¿s condition.
• Performs disease management for members with specific chronic diseases. Performs initial assessment which is used to determine the member¿s level of knowledge about their disease, as well as the need for education, coaching and support to ensure compliance with a treatment plan based on nationally recognized standards of care for their chronic illness(s). Works with patients to create disease specific disease management plans to address their specific objectives and goals established during the initial assessment.
• Responsible for timely contact of members enrolled in the Disease Management program. Maintains appropriate caseload, follows Disease Management process to include appropriate documentation and follow-up.
Competencies and skills:
• STANDARDS OF BEHAVIOR: Acts in a manner that supports the standards of communication, respect, privacy, and teamwork by demonstrating a commitment to professional and ethical conduct.
• CUSTOMER SERVICE: Demonstrates commitment to service excellence by promptly addressing internal/external customer issues/requests, resolving concerns while maintaining a professional image and behavior to build and enhance the patient/family/customer experience.
• ACCOUNTABILITY: Accepts ownership of job roles and specific assignments/goals; works independently, takes responsibility for own actions; admits mistakes and judgment errors; and accepts constructive feedback. Connects personal work results to the accomplishment of team and organizational goals.
• RESPONDING TO CHANGE: Accepts change and adapts in a positive and productive manner; handles unexpected situations and changes in direction calmly and with confidence. Views new assignments and job responsibilities as an opportunity for growth.
• ANALYSIS AND DECISION MAKING: Uses decision making processes and tools to analyze situations and make effective decisions.
• TEAM WORK: Contributes to fullest potential to achieve team goals.
• PATIENT AND FAMILY CENTERED CARE: "Provides Patient and Family Centered Care to patients, families, visitors and internal customers"
• CLINICAL POLICIES AND STANDARDS: Applies knowledge of clinical standards, policies, and procedures relevant to function and organization.
• BLS Certification
• Registered Nurse License
Complexity of Work: This role requires critical thinking skills, effective communication, decisive judgment, and the ability to build and foster positive relationships.
Required Work Experience: Minimum 3 years in acute care nursing/outpatient clinics OR minimum 3 years in care management.
• Bending and Stooping 60.00%
• Keyboard Entry 80.00%
• Lifting or Carrying 0 - 25 lbs Non-Patient 60.00%
• Pushing or Pulling 0 - 25 lbs Non-Patient 60.00%
• Pushing or Pulling 26 - 75 lbs Non-Patient 60.00%
• Pushing or Pulling > 75 lbs Non-Patient 60.00%
• Reaching 60.00%
• Repetitive Movement Hand/Arm 80.00%
• Sitting 80.00%
• Standing 80.00%
• Walking 80.00%
• Audible Speech 80.00%
• Hearing Acuity 80.00%
• Depth Perception 80.00%
• Distinguish Color 80.00%
• Seeing - Far 80.00%
• Seeing - Near 80.00%
• Computer Monitor 80.00%
• Wet or Slippery Surfaces 40.00%
Memorial Healthcare System, consisting of 6 acute care hospitals, a nursing home, outpatient facilities, home health services and physician practices, provides quality, comprehensive care to the residents of the surrounding communities. We invite you to join one of the nation's leading healthcare systems, recognized for use of advanced technology and clinical informatics.
Memorial Support Services provides a variety of business services to support our facilities. The main offices are located in Miramar with satellite offices located throughout our system.
Disclaimer: This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification.