ACO MANAGER

 The role of the ACO Case
Manager is to support the Care Team
(Provider, nurse, medical assistant, other health providers and CCC’s/PCC’s) in
optimizing health and quality of life for individuals with multiple chronic
conditions by: 

Following up on the care for ACO patients, so as to
offer management of care during intervals between face to face interactions
with the healthcare delivery system in Hospitals and Skilled Nursing Facilities
in order to facilitate patients being cared for at the lowest level of care
possible is a critical component of Care Coordination. 

Coordination
of services for all patients who are part of the assigned group, which
includes:  

• All hospitalized patients,
  ER diversion and Skilled Nursing Facilities patients 
• ACO patients with multiple
  (two or more) chronic conditions expected to last at least 12 months, or
  until the death of the patient; 
• Chronic conditions which
  place the patient at significant risk of death, acute
  exacerbation/decompensation, or functional decline; 

Will provide
advocacy, information and referral services to patients and families to address
their medical and psychosocial needs in accordance with the physician’s written
plan of care. 

Qualifications:  

• Knowledge in appropriate
  assessment and assistance techniques. 
• Knowledge in health
  information management by appropriately charting patient data. 
• Knowledge in the utilization
  of tact. 
• Knowledge and demonstrated
  proficiency in performing clinical skills. 
• Ability to communicate
  clearly, with emphasis on excellent telephone skills. 
• Ability to exercise
  professionalism in dealing with all levels of personnel, patients, and
  patients families. 

Responsibilities: 

• Review of the patient care
  plans, initiation of telephone communication to the patients, discussion
  of the care plan with the patient, and, clarification of expectations
  related to the care plan. 
• Creating education programs
  for both staff and patients on High Risk Diagnosis 
• Education and collaboration with Call Centers and
  Office staff to triage clients  
• Assist with implementing
  telemedicine for ACO clients 
• Handle non-appointment
  related calls from assigned patients that involve care coordination,
  follow-up, etc. 
• Assist patients with
  community resources as needed. 
• Keep physician informed of
  patient condition changes and potential changes in the plan of care. 
• Provide an effective
  communication link between assigned patients/caregivers and medical staff,
  including relaying messages from providers, gathering information from
  patients for providers, etc. 
• Support patients and
  providers in the Case Management Program, with care
  compliance when such intervention requires resources, community
  referrals, etc 
• Ensure that all panel patients
  are tracked for follow-up and reporting. 
• Ensure that pertinent data
  and tracking information is entered into the PM and or EMR systems. 
• Quarterly review information
  for assigned patients and verify and validate care delivered to
  proactively coordinate healthcare needs. 
• Coordinate with the medical
  staff to ensure that referral care management services are provided
  to patients with complex medical and/or psychosocial problems. 
• Work with the medical staff
  to develop, implement and carry out programs in chronic disease
  management for patients, with such problems as diabetes, asthma,
  congestive heart failure, hypertension, depression, and other
  disease/condition states based on chronic disease management model. 
• Ensure that disease and quality
  data entry is up to date and use y reports to organize plan of care for
  complex patients. 

Education/Experience: Minimum of
two year’s clinical experience, preferably in a hospital or office practice
setting working with complex medical needs clients.