Clinical Care Manager

Responsibilities:

• Designs and implements care management support activities for high risk patients with chronic diseases and high medical service utilization.
• Collaborates with physician and practice staff in identifying appropriate patients for care management utilizing established criteria. Collaborates with the patient and provider to establish and implement a care management plan using evidence-based guidelines. Develops patient objectives and measures progress according to standards of care.
• Triages patient telephone calls and provides consultation regarding ongoing symptom management resulting from treatment and disease, analysis of intervention regarding diagnostic work-up, assessing and managing acute emergencies, managing family concerns as needed, liaison activities with affiliated physicians, nurses, pharmacists and emergency rooms.
• Initiates appropriate evaluation and management of emergency situations.
• Coordinates patient’s management/treatment plan throughout the institution.
• Instructs patient/family regarding medications and treatments. Educates patients regarding health and illness prevention. Recommends community resources to meet patient and family needs. Develops patient education programs.
• Creates, uses, and maintains patient-specific care management tracking system that identifies/ reports on patients who will benefit from care management services, the subsequent patient progress, and associated interventions.
• Supports QA and maintenance efforts for patient registries and quality reporting. Works with the Clinical Analyst to summarize and analyze data from registries
• Promotes patient self-management and empowers patient and families to achieve optimal health outcomes. Assists patient to identify and/ or develop and utilize their support systems.
• Evaluates the effectiveness of care management plan in meeting established care goals and revises the plan as needed to reflect changing needs, issues and goals.
• Prepares and maintains appropriate documentation as required.
• Collaborates with all members of the health care team to resolve patient health, social or behavioral health needs.
• Provides monitoring and continuity of care between physician visits. Maintains and reviews patient records, charts and other pertinent information.

Credentials:

• Active PA or NJ RN license based on position location. Dual (NJ & PA) RN licensure required within 3 months of hire required.

Education or Equivalent Experience:

• Associate of Arts or Science (Required)
• NLN- approved school of nursing
• Bachelor of Arts or Science
• Nursing 1 years prior nursing experience in internal/family medicine and care management experience