Care Manager, RN at ConcertoHealth
Southfield, MI, US
The care manager acts as an advocate to coordinate the continuum of care for our patients. This role requires a high level of interaction with our patients to:
- Perform effective telephonic outreach to complete necessary health and social assessments
- Engage them in the development of an integrated, patient-centered care plan that takes into account needs across the continuum of care (health, social, psycho-social)
- Support the patient in achieving their own goals as stated in their care plan as well as monitor adherence to treatment plans or other disease/chronic condition management programs
The care manager works with a multi-disciplinary care team to develop interventions and changes to the care plan in response to patient’s needs and promotes positive health outcomes.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Perform comprehensive, team-based, and person-centered patient engagement.
- Conduct patient onboarding, including performing health risk assessments in accordance with (health plan) model of care requirements.
- Creates and develops patient care plans that addresses all problems, goals and interventions identified using appropriate mediums (e.g. historical claims data, outreach logs, completed assessments, etc.) in Concerto’s care coordination record system.
- Identify high risk patients (based on risk stratification criteria) who require a high frequency of care coordination and contact.
- Identifies caregiver training needs and tracks impact of needs and or training.
- Completes transition of care process in accordance with health plan guidelines; includes outreach during hospitalization and conducting assessments upon discharge to ensure successful transition to another setting.
- Identify the appropriate utilization of resources across the continuum of care.
- Participate in quality improvement and evaluation processes.
- Work closely with the Pharmacy Benefit Manager and community pharmacies to help coordinate medication accessibility and medication refills.
- Perform and document reassessments, revisions to care plans, and coordinate interdisciplinary care team meetings in accordance with the (health plan) model of care requirements.
- Coordinate activities with Treating Providers, Utilization Management Team, Social Services Team and Disease Management Team as needed.
- Complete all mandatory regulatory and other trainings required (including but not limited to: compliance training, first tier downstream and related (FWA) entity training, model of care training, etc.).
- Knowledge of Healthcare Effectiveness Data Information Set (HEDIS) and engagement with members on care gap closure.
- Regular and consistent attendance.
- Other duties as assigned.
- Current RN License in good standing in the state of practice required Preferred Certified Care Manager (CCM) certification or commitment to completion within 1 year of hire.
- Minimum of 3 years’ experience in a clinical setting.
- Demonstrates the ability to triage and apply critical thinking skills.
- Ability to communicate effectively in writing and verbally.
- Knowledge of Medicare and Medicaid care management requirements in accordance with CMS and MDHHS guidelines (or similar program for dual eligible beneficiaries).
- Health Plan, Patient Centered Medical Home or CPC+ experience is preferred.
- Proficient in computer skills to include Microsoft Office Suite (Outlook, Excel, PowerPoint, Word). knowledge and ability to navigate internet based tools, and proficient in computer typing with a minimum typing speed of 40 WMP.
- Demonstrate ability to perform multiple concurrent tasks with minimal supervision and meet compliance deadlines.
- Ability to work in fast-past environment.
- Experience working in field-based role.
- Reliable transportation is required.
- Person-centered care plan preparation experience is required.