Description

General Purpose of Job Position: The Care Manager's primary responsibilities include managing the care of identified patients using risk stratification, data resources and provider recommendation. The care manager contacts patients in person during office visits and telephonically and performs a risk assessment, developing a patient centered care plan including SMART goals and expected patient outcomes. The care manager utilizes appropriate resources, education materials, community services, and works with the provider throughout the process. The care manager offers nursing support/care coordination to the practice program(s) in order to optimize patient outcomes and to improve patient's quality of life through clinical and educational programs and/or support services.

Essential Job Functions, Duties, and Responsibilities: The following list of duties is not intended to be restrictive or all inclusive. The fact that certain duties may not be listed does not limit the assignment of additional and/or other duties.

• Triage and directs patients and/or families to appropriate resource utilization by working with providers, staff, third party payers, families, community resources, etc. to facilitate care of the patient throughout the continuum of care. 
• Triage by phone and in-person to evaluate social determinacies of care and supply resources to patients and families. 
• Serves as a resource contact and information/education source to patients, families, providers, and/or staff.
• Works with provider(s) and staff to ensure the delivery of quality care to patients to ensure best patient outcome.
• Triaging patients to follow-up with their provider based on chronic conditions and level of care needed.
• Receive discharge information from hospitals regarding inpatient discharges, emergency departments, rehabilitation facilities, and skilled nursing facilities through online portals.
• Contact patients by phone that have been discharged to gather information about their conditions and schedule a face-to-face appointment with their provider based on the phone triage urgency. 
• Research Medicare/Medicare Advantage patients and work with Medicare/Medicare Advantage insurance companies to schedule and retrieve documentation for closing Preventative Medicine and Chronic Conditions Care Gap's. This includes but is not limited to hypertension & diabetes follow-ups, mammograms, colonoscopy's, retinal eye exams, etc.
• Complete medication reconciliation by phone and in-person triages.
• Maintains knowledge and satisfactorily complies with regulatory procedures, notification requirements, documentation required in the medical record, etc.

Requirements

MINIMUM QUALIFICATIONS AND STANDARDS

Education: Certified or Registered Medical Assistant

Experience: 1 year or greater of consecutive patient care

Certifications/Licensure: RMA/CMA with excellent experience considered. CPR/BLS required.

Knowledge, Skills, and Ability Requirements

• Possesses outstanding interpersonal skills, including excellent written and verbal skills and ability to speak with patients clearly and effectively
• Performance improvement or patient safety knowledge required
• Thinks critically; utilizes sound judgment; promptly reports potential patient safety risks to provider and/or manager
• Demonstrates good organizational skills in the preparation of daily work schedules and the assignment of duties and
  responsibilities
• Ability to effectively work with and through physicians, subordinates, customers, and other personnel in a cooperative, collaborative manner in order to improve clinical quality outcomes
• Ability to efficiently and effectively manage multiple tasks with excellent time management skills
• Ability to work in a fast paced, patient service oriented environment and is self directed
• Demonstrates ability to promote quality improvement through development and maintenance of standards
• Ability to maintain professional conduct in all work-related and/or emergent situations
• Experience working with computer systems; proficient with EMR, Microsoft Excel, Word and computer programs