Care Manager; RN or LCSW

Overview

The Care Manager addresses the needs of the population served by assessing, planning, implementing, coordinating, monitoring, and evaluating the options and services required and using communication and available resources to promote quality, cost-effective health outcomes. Works within the Registered Nurse scope of practice, and in concert with the Primary Care Provider, patient, caregivers, family members, other members of the Care Management Team and the community to coordinate a full continuum of health care services considering the holistic needs of the member, inclusive of unique social and cultural dynamics.

In addition, this position will support CCHC goals and objectives in meeting performance improvement targets for various initiatives, data analysis that supports care management, standardized plan of care expectations, and patient team development and perform other duties as assigned like the occasional need to triage patients to support the development of the network.

• Provide effective Care Management services based on case management standards of practice to enrolled populations
• Complete comprehensive assessments considering the total individual, inclusive of medical, biopsychosocial, behavioral, spiritual and cultural needs to enrolled population, throughout the continuum of care
• Develop, review, and evaluate the member care plan in partnership with the member, caregiver/family members, providers, and Care Management team members, as applicable
• Work with patients to identify behavioral, social, cultural, and environmental strengths and challenges as it relates to his/her diagnosis, treatment, and access to care.
• Occasional need to triage patients.
• Identify and address barriers that impede health outcomes
• Implement Care Management interventions per the patient’s care plan
• Work in conjunction with patient to formulate, develop, and implement patient-centered plans using therapeutic skills and techniques such as trauma-informed care, motivational interviewing, strengths-based, and solution-focused modalities.
• Provide education to patient/family about clinical diagnosis, medications, available resources, prevention, and risk factors to achieve optimal self-management
• Utilize therapeutic skills and techniques to help patients achieve healing, growth, health, and wellness
• Monitor quality and effectiveness of interventions to the enrolled populations by setting patient-centered SMART goals in collaboration with the patients/families
• Processes referrals to members of the patient engagement team (social work, behavioral health, community resource coordinators) and/or clinical team (pharmacy, pharmacy technician, patient coordinator) appropriately, accurately and timely according to established workflows
• Serve as a liaison among the patient/family, community services, primary providers, specialists, and other care team members to coordinate services without duplication
• Work collaboratively with multi-disciplinary team members to facilitate achievement of desired treatment outcomes
• Maintain appropriate member documentation in the Care Management documentation platform, in accordance with organizational policies and procedures
• Engage and maintain collaborative relationships with community provider agencies that promote quality care and cost-effective health care utilization
• Adhere to CCHC privacy and security policies to ensure that patient and network data are properly safeguarded
• Abide by department guidelines, company policies, and HIPAA regulations.
• Attend departmental and corporate meetings, local and regional training’s, or other events as required
• Willingly performs other duties as assigned.
• Works under the direct supervision of the Director of Nursing

• Licensed and credentialed Registered Nurse or Licensed Clinical Social Worker (LCSW).
• Bilingual preferred, but not required
• 3-5 years’ experience in clinical or community resource settings with; care coordination and/or case management experience
• Evidence of essential leadership, education, counseling skills, and strong interpersonal skills; ability to work with colleagues across sites.
• Proficiency in communication…