Description

POSITION DESCRIPTION:

Responsible for providing and coordinating screening and care management interventions for patients identified with chronic, complex, care needs based on patient information provided by Managed Care Organizations (e.g. Aetna Medicare). Works collaboratively with the ACO Care Management team to implement evidence-based series, protocols, and methods for eligible patients. Responsible to assist with hospital follow up for FHC patients based on hospital discharge lists received from Lee Health and our contracted insurance plans. MCO Care Manager will be required to attend applicable insurance’s monthly or quarterly meeting and will have the chance to discuss their results, questions, and issues with the insurance reps during that time. The MCO Care Manager may also participate in other report analysis and patient contact projects, aimed at improving patient healthcare through increased contact and the scheduling of regular visits. Adheres to Corporate Compliance program, by reporting improper or unethical conduct, violation of applicable laws, regulations, or program requirements.

DETAILED DUTIES AND RESPONSIBILITIES:

• Ensures consistent use of an initial HRA for patients deemed eligible for care coordination.
• Conducts initial visit with more comprehensive HRA if needed, to detect level of care coordination/management needs.
• Understands the role and use of clinical protocols and standing orders for chronic disease management.
• Uses other team members as appropriate to co-manage patients if needed.
• Works with patients and providers in the creation of a care plan, or in review and update if there is an existing care plan.
• Uses a variety of education materials, brief intervention techniques, and community resources to engage patients, increase their motivation to change, and support patients in establishing behavior change goals and implementing plans to meet those goals.
• Establishes a follow-up schedule and monitors patients’ progress based on patient’s documented risk level determined by HCC Category Disease States, compliance, and hospital / ER usage.
• Effectively and accurately uses Electronic Health Records (EHR) to document and track patient history.
• Maintains accurate and up-to-date records and standardized data on all patients.
• Clearly and effectively communicates with the patient, PCP, and any external providers, including information from the PCP about the patient’s progress and discussing side effects and care plan with the PCP and other care team members as needed. Requests records from outside providers as needed to close gaps and for continuation of patient care.
• Develops a maintenance plan with patients, when appropriate, to help them maintain a healthy lifestyle and prevent a reoccurrence of symptoms of their chronic condition(s).
• Refers patient to in-house services lines as needed.
• Develop understanding of HCC risk coding and stay up to date with yearly changes. Use this understanding to add appointment notes requesting condition assessment at annual and / or established visits.
• Assists with hospital follow up call outs to FHC patients based on external discharge lists received.
• Required to attend annual Cologuard training.
• Willing to work on other HEDIS pilot programs as assigned.
• Attend and contribute to monthly HEDIS department meeting.
• Other duties as assigned.

Requirements

KNOWLEDGE, SKILLS AND ABILITIES:

• Strong interpersonal skills.
• Comfort with patient-centered approach that allows the patients desires around behavior change to inform the plan of care.
• Clinical skills or aptitude in problem-solving and strategies for behavior change, including Motivational Interviewing and Behavioral Activation.
• Ability to serve as a critical liaison to facilitate connections between people in a collaborative role and oversight to a care coordinator, if applicable.
• Ability and willingness to work in a time-limited, structured, and solution-focused environment.
• Ability and willingness to function independently and proactively in a primary health care setting.
• Ability to maintain a professional stance if conflicts arise with other staff.
• Flexibility to adapt to unforeseen needs or circumstances.
• Effective use of the Internet and the EMR systems within the work environment.
• Knowledge of HCC Coding and ability to stay up to date with HCC coding changes and requirements from insurance companies that are part of this care management program

TRAINING AND EXPERIENCE REQUIREMENTS:

• Minimum 2 years’ experience in primary care setting.
• Bilingual (Spanish/English) preferred.

SPECIAL REQUIREMENTS:

• Computer abilities: word processing, excel spreadsheet experience (including editing, filtering, and creating graphs and tables) and presentation software
• Must be able to travel to all offices.