Care Manager - Advocare : Job Details

The Care Manager position is responsible for managing high risk, high-cost, and chronically ill patients to promote effective self-management, education, and timely healthcare delivery to achieve optimal quality and financial outcomes. Responsibilities include coordinating patient care to improve quality of care through the efficient use of resources and thereby enhancing quality, cost-effective outcomes. Acts as an advocate for an individual's healthcare needs, and coordinates care to minimize the fragmentation of health care delivery systems. This position is committed to the constant pursuit of excellence in improving the continuity of care and meeting the Quadruple Aim.Advocare, LLC is a partnership of the top doctors in New Jersey and Pennsylvania, including pediatricians, family practice and specialists. As part of the team, you'll work side-by-side with forward-thinking professionals who strive to provide the highest quality medical care by meeting and exceeding standards for clinical outcomes while delivering exceptional patient service in an evolving healthcare environment.Essential Functions:Collaborates with providers and practice staff in identifying appropriate patients for care management, utilizing established Care Management criteria. Performs initial and periodic assessments for assigned patients. This includes health risk and psychosocial assessments as appropriate. Creates and implements a care plan that is mutually agreed upon by the health care team and the patient/family that addresses the patient's identified needs based on the assessment of the patient/family needs, health issues, resources, and care goals. Determines the best choices available to individual patients and educates the patient/family on the choices available. Plans specific self-management goals, objectives and interventions with patients that are action oriented. Monitors and evaluates the progress of the patient by determining the effectiveness of the care plan in meeting established care goals. Revises the care plan as needed to reflect changing needs, issues, and goals of the patient. Collaborates with the healthcare team to revise the care management plan when changes occur. Initiates care conferences as appropriate to discuss multidisciplinary team responsibilities, patient progress, new problems, etc. Identifies community resources to meet the needs of patients/families. Facilitates patient access to community resources as appropriate. Performs follow up calls according to the TCM workflow for patients recently discharged from acute hospitalizations and who are at high risk for readmission. Collaborates with providers, other healthcare team members to include inpatient facilities, the patient's payer, and health system administrators to transitions of care and facilitate care across the healthcare continuum and optimize clinical and financial outcomes. Suggests and completes appropriate referrals. Serves as a liaison to providers, patients, and families for coordination of services. Maintains a working knowledge of payer requirements (HEIDIS, etc..).Develops collaborative working relationships with insurance case managers; communicates on behalf of patients with third parties for cost-effective, high-quality services and to maximize the efficient use of resources. Maintains accurate and timely documentation. Strives to meet established standard for productivity. Review utilization and quality reports routinely and scans for gaps in care and to identify patients needing the additional support of care management. Participates in regular team meetings and peer review activities. Participates in departmental and organizational committees, as applicable. Participates in the orientation of new personnel. Precepts and mentor peers. Promotes collaborative teamwork. Meets with the care management team leader, and the care management team on a regular basis to provide patient updates identify issues and develop strategies for resolution. Participates in patient case reviews for strategic collaboration on patient issues. Performs all duties and responsibilities in accordance with the Nurse Practice Act, Department of Nursing Regulations and in accordance with basic principles and guidelines of professional nursing. Maintains appropriate professional boundaries. Ensures documentation meets current standards and policies. Maintains a working knowledge of, and adheres to applicable federal and state regulations including, but not limited to, laws related to patient confidentiality, release of information and HIPAA. Performs all other duties, as assigned by supervisor.Required Skills/Abilities:Excellent written, verbal and listening community abilities. Communicate appropriately and clearly to staff and providers. Ability to manage conflict, stress and multiple simultaneous work demands in an effective and professional manner. Ability to work well independently, while collaborating with other team members. Serves as a clinical resource person to staff. Ability and willingness to self-motivate, to prioritize and change processes to improve effectiveness and efficiency. Adapts to changing patient or organizational priorities. Ability to make independent decisions in accordance with established policies and procedures. Decisions and problem solving require a combination of analysis, evaluation, and interpretive thinking. Knowledge of and appreciation for cultural diversity and low literacy issues in care provision. Computer literacy, including, by not limited to, data entry, retrieval, and report generation. Ability to work with patients/families of all ages and in a variety of settings, including office facilities and patients' homes, presenting diverse physical conditions and social/cultural environments.Ability to operate a keyboard, photocopier, telephone, computer applications and other office equipment for large amounts of timeEducation and Experience:Licensed Registered Nurse by the State Board of Nursing requiredBachelor's degree required3 years minimum of clinical experience required2 years minimum of hospital experience requiredCare/case management experience preferred