Care Manager - Pediatrics

This is a Pediatric Care Management Position embedded in a Pediatric office.

The Care Manager I is an integral member of the office care team. Provides care management and care coordination for patients that are experiencing a transition of care, undergoing treatment or have moderate to complex illness, while working under minimal supervision.

• Collaborates with members of the health care team and patient to ensure the delivery of quality, efficient, patient centered, and cost effective healthcare services.
• Assists patients who are at risk for developing chronic conditions to minimize these risks by providing self‑management support and patient education; empowers patients to manage their health.
• Provides targeted interventions to avoid hospitalization and emergency room visits; in specialty population the care manager ensures proper triaging of the patient and appropriate delivery of care in accordance with established protocols.
• Assesses, plans, implements, monitors, and evaluates delivery of individualized patient care with the goal of optimizing the patient’s health status.
• Serves as an active member of the office based care team and works closely to support identification and referrals of eligible patients for care management support.
• Participates in the outreach and engagement of patients that are hospitalized to assist with the transition of care and provides support and education to avoid further readmissions.
• Coordinates the care and services of selected member populations across the continuum of care, promotes effective utilization and monitoring of health care resources, and assumes a collaborative role with all members of the healthcare team to achieve optimal clinical and resource outcomes.
• Maintains the ability to utilize guidelines and standards of care for management of chronic diseases.
• Makes “cold calls” and engages patients into the program effectively.
• Identifies common populations/high volume complex populations within the practice and prioritizes and directs interventions.
• Clinical responsibilities include:
• Coordinates and provides patient education for common patient populations within the office.
• Designs individual plan of care for patients based on evidence‑based guidelines.
• Fosters a team approach by collaborating/referring patients to supporting members of the care team (RD, CDE, pharm, panel manager etc.) and ensures coordination of services.
• Assesses health behavior and disease‑specific risks; identifies a plan of action for patients.
• Assures clinical compliance with follow through utilizing reminders, follow‑up calls, patient and office education.
• Refers selected patients to determined community resources and coordinate with these resources.
• Provides patient‑specific feedback to providers and clinical team.
• Provides face‑to‑face and telephone interactions with patient population.
• Utilizes relevant computer information support including the EMR and any other care management and/or clinical IS systems needed to complete the tasks of clinical care and performance reporting.
• Works with patients and providers to customize services that will best meet the needs of the patient and work within their benefits.
• Researches and facilitates services for patients outside of their benefits while utilizing community services and resources.
• Assists in orientation process by having new CM shadow.
• Provides feedback on the CM orientation process.
• Evaluates and manages day to day workflow and adjusts as needed to increase efficiencies.
• Attends required meetings and training, and participates in committees as requested.
• Assists with special projects and performs other duties as assigned and works within the scope of RN licensure.

• Performs assessments of the home and social determinants of health for individuals aged 65 or older.
• In collaboration with the Home Based NP and/or primary care physician the care manager works to implement a plan of coordinated care that supports the individual’s goals, strengths and preferences.

• Creates a positive, professional, service‑oriented work…