ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.

Other duties may be assigned.

• Manages a caseload of an assigned panel of chronic care patients, including patients with mental health issues.

• Collaborates with physicians, providers, and practice staff in identifying appropriate patients for care management.

• Develops relationships with patients as an integral member of the team.

• Provides follow-up management with patients to ensure compliance with their individual care plan.

• Maintains availability to provide telephone advice per protocol, and handles urgent and emergency calls during working hours.

• Anticipates the needs of the patient population, seeing that necessary documentation and pre-visit planning is completed or requested before patient visit.

• Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence.

• Determines and coordinates appropriate referrals as needed.

• Works with patients and patient’s care team to coordinate change readiness, needs assessment and to develop an individualized treatment care plan.

• Collaborates with the patient, physician, and other care team members in assessing the patient’s progress toward individual health care goals.

• Maintains accessible, consistent documentation of patient self-management measures, and reporting progress toward goals.

• Assists patients in setting SMART goals for self-management, teaching them how to do self-management tasks, and reports abnormal findings to their physician team.

• Assesses barriers when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments.

• Participates in regular team meetings and peer review activities.

• Promotes collaborative teamwork and is able to work with peers in a team situation.

• Collaborates with payer Case Managers for additional services when appropriate.

• Maintains a list of medical supply and community resources available to patients and maintains collegial relationships with the entities used most frequently.

• Makes recommendations for policies/procedures to ensure that preventive services are offered in a timely manner to all who qualify.

• Provides follow-up in the transitions of care from various settings (hospital or skilled nursing facility discharges and emergency room visits).

• Coordinates disease registry activities.

• May conduct home visits with a physician in order to assess safety, medication compliance, and home environment.

• Participates in departmental and organizational committees as applicable.

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this job.

KNOWLEDGE, EDUCATION AND/OR EXPERIENCE: The Care Manager must have knowledge of the Patient-Centered Medical Home model/mission as well as knowledge of insurance industry practices and requirement. He/she must have an understanding of chronic disease and preventive care measures. Must have a bachelor’s degree in health care administration, health informatics, or a related field and hold licensure as a Licensed Practical Nurse, or an incumbent holding licensure as a Licensed Practical Nurse and having significant experience in chronic care may be considered. Licensure as a Registered Nurse is preferred. Experience working with patients with mental health issues is preferred.