Care Manager

The Care Manager (CM) works with the patient population and other JHC staff to support a patient centered, model of care. The CM will assess, plan, facilitate, coordinate, and evaluate patient needs and, with patient consent, create an agreed upon plan of care to facilitate medical self-management and wellness.

1. Identifies patients who have complex medical issues (such as those having several diagnoses, chronic illnesses, complicated treatments, multiple providers) in order to assist and educate patients regarding their conditions and treatment plans, and aid in care coordination

2. Advocates for patients’ health literacy and medical self-management; educates patients to empower them to be active participants in the health care and treatment options by informing and collaborating with patients regarding their health care needs.

3. Develop and implement care plans that involve patients, caregivers and family to meet health care needs. Monitors adherence to individualized plan of care.

4. Manages patient caseload based on acuity level of follow-up;

5 Promote wellness through one on one education by identifying barriers to care and assisting with lifestyle changes.

6. Responsible for building one on one rapport with patient to improve patient engagement and self- care management.

7. Monitors ER/discharge reports from the hospital to assist with coordination of care and Transitional Care Management after discharge. Assesses discharge information and connects the patient with healthcare professionals; educates and supports treatment regimen adherence and medication management.

8. Performs medical triage as needed to provide appropriate guidance through education and scheduling of appointments based on current health status and needs.

9. Performs on-going assessment of patient needs and individual care plan by having direct patient/patient representative contact (face to face or telephone), and confers with medical staff to address gaps in medical care through patient outreach, education and coordination of care;

10. Serve as a resource for Care Management Coordinators by providing training and guidance in addressing individual patient needs.

11. Educates medical staff regarding individual patient issues and barriers as well as general health risk management and population issues.

12. Participates in patient care team meetings to maintain patient-focused care and work flow processes.

13. Facilitate patient education programs (ex: Diabetes Prevention Program) to proactively address preventable health problems and manage existing chronic health problems and works with provider care teams to identify patients who may benefit from different educational programs.

14. Works with the Director of Care Management to identify center-wide care issues and improve work processes.

15. Other clinical duties and responsibilities as assigned by the Director of Care Management.

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1. Employee will abide by the Code of conduct as documented in the Corporate Compliance Manual.

2. Must demonstrate a personal and professional commitment to Johnson Health Center and its mission.

3. Management may modify, add or remove any job functions as necessary, or as changing organizational needs require.

Actively demonstrates dedication and commitment to the JHC core values:

1. Respect- We value and respect each patient, their family, ourselves and each other.

a. Every individual associated with JHC will be treated with dignity and respect. We value and respect people’s differences, show empathy to our patients, their families and each other, and work collectively to build Johnson Health Center as a health center and an employer of choice.

2. Integrity – We are committed to doing the right thing every time.

a. Our actions reflect our commitment to honesty, openness, truthfulness, accuracy and ethical behavior. We are accountable for the decisions we make and the outcome of those decisions.

3. Excellence – We will pursue excellence each and every day in activities that foster, teamwork, quality improvement, patient care, innovation and efficiencies.

a. At JHC, our medical, dental, pharmacy, behavioral health, front desk and administrative teams are passionately committed to the highest quality of care for our patients. We continually seek out ways to enhance the patient experience and promote an environment of continuous quality improvement.

4. Innovation – We value creativity, flexibility and continuous improvement efforts.

a. We are advocates and instruments of positive change, encouraging employees to engage in responsible risk-taking and working to make a difference. Out of the box thinking enables us to build on successes and learn from failures.

5. Teamwork – We understand that teamwork is the essence of our ability to succeed.

a. We work across functional boundaries, embracing diversity, for the good of the organization. Our collaborative approach ensures a culture of participation, learning and respect and serves to improve the quality of patient care. By focusing on a team based approach, the expertise of each Johnson Health Center employee is leveraged to optimize the patient experience.

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The CM reports to the Director of Care Management. The CM may assist the COO with any issue that requires clinical expertise.

The evaluation of work performance will be on-going, and will be carried out by the Director of Care Management. The Director of Care Management will provide the CM with an evaluation regarding job performance. It will include the specific duties and responsibilities of this position description plus employee attitude and general working behavior. Formal evaluation will be performed annually, but may be initiated at other times by the CM or Director of Care Management.

1. Must be licensed with the Virginia State Board of Nursing with a current RN license.

2. Minimum of 3-5 years’ RN experience.

2. Must have graduated from an accredited nursing program. Certified Care Manager (CCM) is preferred.

3. If certified, maintains Certified Care Manager status as directed by governing agency and maintains the appropriate continued education criteria.

4. Ability to work a flexible schedule.

STATUS:

This position is a FLSA Non-Exempt position.

This is an ADA negotiable position.

SALARY:

This position is a grade C6. The salary for this position is negotiated between the individual and the Director of Human Resources and/or the Chief Executive Officer.

Updated: 07.23.19