Job Description:

Job Summary:

Working in collaboration with Spectrum Providers, Community Health Workers, Case Managers, Behavioral Health Consultants, Specialty Care Practices, Health Plan staff, Home Health Agencies, and others, the Nurse Care Manager identifies and proactively manages the needs of patients with high risk or complex medical, behavioral health and/or psychosocial problems through office visits and telephonic support.

The Nurse Care Manager works with patients to develop and implement care plans based on patient goals, preferences, and disease states to promote improved health outcomes and quality of life. This individual will work as part of a system-wide team comprised of nurses, community health workers, and case managers. The Nurse Care Manager connects patients with appropriate internal and resources and community resources, facilitates referrals to appropriate care services, and supports patient self-management, and communicates with other care team members to reduce barriers to improved health care outcomes. The Nurse Care Manager serves as an integral member of the care team, assesses patients for risk of adverse health outcomes and high utilization of acute care services, and monitors the impact of care management interventions.

This position will, once fully trained, be primarily located at our Cottman Avenue Health Center, a new and growing site that serves a culturally and linguistically diverse patient population. Business needs could require that presence at any of Spectrum's other sites could also be necessary.

Essential Functions - include, but are not limited to:

Provides Care Management Services

• Identify patients at high risk of adverse health outcomes (e.g., death, disability, inpatient admission, SNF admission or ED visit) through case finding activities including physician referrals, hospital/ED utilization data, payor reports, claims, or encounter data review identifying high cost/high risk disease states or patients.
• Provide comprehensive transitional care management involving coordination of care and services following critical events, such as emergency department use, hospital inpatient admission and discharge or skilled nursing facility admission and discharge.
• Build a panel of patients with high risk or complex medical, behavioral health and/or psychosocial problems and conduct regular longitudinal goal-directed outreach in person and telephonically. Ensure patient understands program benefits, care manager’s role, how to make best use of the program, and obtain consent to participate.
• Engage patients in trusting relationships enabling effective intervention and support.
• Utilize motivational interviewing to conduct assessment(s) of patient condition, needs, preferences, clinical and psychosocial/SDOH barriers to optimal health and identify care/case management intervention opportunities.
• Develop a person-centered care management plan based on the patient's goals, strengths, and barriers to promote improved health care outcomes and quality of life. Ensures care plan goals are clear, actionable, measurable, and time sensitive.