Care Manager

New Jersey
Nov 07, 2020
Internal Medicine
Position Type
Job Description

The RN Care Manager will participate in a dynamic interdisciplinary team to provide case management services to identified complex, high-risk patients across the care continuum. The Care Manager will partner with patients and families by engaging them in the accountability of care in order to improve patient experience. The Care Manager will achieve goals of lowering costs and improving clinical outcomes by serving as an integral primary care team member, managing assigned populations of patients, and coordinating care for patients identified with potential avoidable utilization, gaps in care, and/or at-risk status. Responsibilities may include development of care plans, collaboration with external agencies, case conferences, self-management support and health coaching. RN Care Managers may also administer vaccines as needed in the home at the direction of the provider and take and report patient vital signs, as needed.

Essential Job functions
  • Works with multidisciplinary transitional care team to facilitate seamless patient transitions across the continuum of care.
  • Assesses assigned population of patients. Independently prioritizes care management needs (high need, high-risk and/or high cost).
  • Applies case management concepts, principles and strategies to assist the high-risk patient in achievement of prevention and treatment goals.
  • Care plan development and monitoring for the highest need/highest cost patients in collaboration with the Primary Care Physician.
  • Proactively identifies and refers appropriate candidates to the Telehealth program as a means of trading high-cost acute care services for lower cost care management.
  • Documents appropriately in the electronic health record, care management registry and any required patient tracking documents. Employs appropriate and timely use of tasking in the EHR. Reviews and updates medication and problem lists.
  • Performs all care management activities across the continuum of care while adhering to the core values of patient confidentiality, privacy, safety, advocacy, and adhering to ethical, legal, and accreditation/regulatory standards.
  • Delivers care management services within the scope of licensure in accordance with SMG policy.
  • Assumes accountability for the quality of care.
  • Continually seeks new knowledge and learning regarding comprehensive primary care and chronic disease management.
  • Administer vaccines as directed by the provider
  • Take and report vital signs as needed.
  • Other duties as assigned.

General Job functions:

1. Transitional Care Management:
  • Ensures that all assigned "Hospital Discharge" and "Rehab Discharge" tasks in the EHR are addressed in a timely manner, identifying whether the patient requires follow up with primary care or a specialty department at SMG.
  • Performs telephonic outreach to patients within 2 business days of discharge.
  • Documents all the elements for transitional care management in an Encounter in the EHR.
  • Ensures that the Transitions of Care note is sent to the appropriate PCP for review and signature in the EHR.
  • Schedules follow-up appointment(s) for patients in Athena. High complexity patients are scheduled within 7 calendar days post discharge. Moderate complexity patients are scheduled within 14 calendar days post discharge.
  • Follows the patients' status for 30 days, updating the Primary Care Physician and communicating with family members as needed. Ensures outreach to patient post discharge day #30 to confirm that patient has not been readmitted.
  • Provides continued intense care management to the highest risk patients beyond the 30-day period as clinically warranted.

2. High-Risk Patient Identification and Management:
  • Identifies high need, high-risk and/or high cost patients through Transitions of Care, payer-provided data, and physician referrals.
  • Performs full chart review taking into account chronic disease(s)/disease burden, significant risk factors, polypharmacy/pill burden, functional status, utilization and social issues.
  • Risk stratifies patients into 1 of 6 levels of risk utilizing AAFP's algorithm for risk stratification. Patients in levels 5-6 are placed in high-risk panels for intensive care management.
  • Identifies any gaps in care and determines the needs prior to outreach.
  • Performs outreach to patients scheduling/facilitating any appointments for needed care with Primary Care Physician or specialist, addressing any gaps in care, providing education regarding disease/illness, medication and self-management.
  • Initiates collaborative Care Plan with patients in close collaboration with the Primary Care Physician.

3. Care Plan Development:
  • Initiates Care Plans for the highest need/highest cost patients in close collaboration with PCP, patient and family; updates Care Plans as needed.
  • Incorporates clinical service team and physician feedback into care management planning.
  • Collaborates with all members of the health care team to include members of the interdisciplinary care team (e.g., Social Worker, Clinical Pharmacist, Certified Diabetic Educator, etc), the patient and their family members as appropriate.
  • Engages high-risk patients (and their caregivers) in understanding and setting self-management plans in a culturally and linguistically appropriate manner.
  • Supports high-risk patients in their health behavior change efforts.
  • Provides ongoing monitoring of patient involvement, participation and compliance with treatment plan, updating Care Plan as needed.

4. Telehealth:
  • Demonstrates knowledge of the program, program criteria and referral process to program.
  • Proactively identifies patients with CHF and/or COPD that are appropriate for referral, e.g. post discharge from inpatient facility or ED.

5. IS/Care Management Registry:
  • Demonstrates ability to use the EHR, care management registry, and all ancillary clinical systems efficiently and effectively for communication and documentation purposes.
  • Develops super-user knowledge of the Care Management Registry.
  • Utilizes the Care Management Registry to identify and track the top 3-5% highest risk patients.

6. Payer Contracts:
  • Demonstrates a broad understanding of payer contracts (e.g., understanding patient attribution, care management requirements, clinical quality metrics, and utilization and cost outcomes).
  • Ability to work with payer provided reports.

7. PCMH:
  • Demonstrates knowledge of PCMH requirements and standards.
  • Ability to implement the workflows that are specific to Care Management.
  • Demonstrates the ability to effectively communicate and collaborate with care team members.

8. Competency, Training and Education:
  • Maintains core proficiencies /competencies as defined by the Care Management Program.
  • Continually seeks new knowledge and learning regarding comprehensive primary care and chronic disease management.

9. Quality Improvement Initiatives:
  • Serves as a resource for all current and future quality improvement initiatives within SMG.
  • Demonstrates ability to appropriately document data discretely in the EMR and serves as a resource for clinical office staff

Education, Certification, Computer and Training Requirements:
  • Bachelor's Degree preferred but not required
  • Valid NJ RN License Required
  • Valid Driver's License required & proof of valid vehicle insurance (NJ Coverage limits required)
  • Proficiency in vaccine administration
  • Proficiency in taking BP, P and other vital signs for reporting
  • Certified Case Manager (CCM) preferred
  • Demonstrated ability to work in a collaborative team oriented environment
  • Ability to communicate in English, both orally and in writing required.
  • Proficient Microsoft Office skills preferred
  • Experience with standard office equipment (phone, fax, copy machine, scanner, email/voice mail) required.

  • A friendly and fast-paced environment working with passionate people
  • Outstanding growth opportunities
  • Time Off
  • Medical, Dental and Vision Insurance
  • Short/Long Term Disability, HSA, and Life Insurance
  • 401K plan with company matching contribution
  • Cash Bonus Programs
  • Recognition and rewards programs to recognize successful teams
  • Other Perks & Discounts
  • Commuter and parking discount program to help you save (using pretax dollars)

*Full Time Benefit Eligible Employees Only

Equal Opportunity Employer

Our Company provides equal employment opportunities ( EEO ) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws.

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