Advanced Heart Failure Care Manager

Advocate Health•Greenville, SC

13d•$38 - $57•Hybrid

About The Position

The Advanced Heart Failure Care Manager facilitates communication among patients/families, the multidisciplinary team, medical management, and community resources to proactively identify and resolve barriers to timely care delivery. This role involves interpreting contracts to achieve optimal clinical and financial outcomes. The Care Manager collaborates with patients, families, and inter-professional teams, including primary care, hospital care, post-acute care managers, and other partners, to ensure quality, efficient, and cost-effective healthcare services. The position may involve working embedded within a provider office or telephonically. The role utilizes evidence-based approaches to enhance patient and family activation and engagement in their own care, partnering with them to develop SMART goals and assisting in the development and adoption of self-management educational resources. The Care Manager identifies potential barriers to learning or optimal care delivery, reports abnormal findings to the responsible provider/care team, and collaborates on a plan. They independently manage their caseload, ensuring timely completion of tasks and documentation related to MCO, regulatory, and contractual requirements. The role partners with at-risk patients throughout diagnosis, treatment, and follow-up to ensure continuity of care, anticipating needs, responding to changes in patient status, and prioritizing care based on essential patient needs. The Care Manager coordinates patient information and communication between patients/families, referring/accepting facilities and physicians, community caregivers, and other team members to ensure smooth transitions of care. They also coordinate referrals to other internal departments and external community resources as necessary. The position requires the ability to provide age-appropriate care, demonstrating knowledge of growth and development across the life span and assessing patient status based on age-specific needs.

Requirements

Registered Nurse license issued by the state in which the team member practices.
Bachelor's Degree in Nursing or related field.
Typically requires 5 years of experience in clinical nursing or 1-2 years of care management experience.
Must be self-directed with the ability to work well independently and within a team environment while recognizing and meeting the individual needs of external and internal partners/customers.
Ability to demonstrate excellent oral, written and interpersonal skills.
Ability to demonstrate critical thinking, problem solving and excellent organizational skills.
Ability to work productively and effectively in a complex environment that includes multiple changing priorities.
Demonstrated ability to work well with physicians and other healthcare professionals in a direct and positive manner.
Proficient computer/Microsoft-suite skills and previous Epic EMR experience.
Ability to handle multiple responsibilities.
Manual dexterity required for operation computer and calculator.
Visual acuity required to facilitate review of written documents/computer screens, medical records, and to record information accurately.
Clear oral communications and hearing acuity required for receiving instructions and converse on standard telephone.
Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone.
Operates all equipment necessary to perform the job.

Nice To Haves

Applicable certification is encouraged.

Responsibilities

Facilitates communications among patient/family, multidisciplinary team, medical management team, community resources and other disciplines to anticipate, identify, evaluate, and act to resolve any potential barriers and constraints to delivery of care in a timely manner.
Understands and interprets multiple contracts and contractual obligations in order to enable the care management team to achieve maximum clinical and financial outcomes.
Collaborates with the patient/family and inter-professional team including the primary care team, hospital care team, post acute care managers, and other care partners to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services.
Uses evidenced-based approaches to increase patient and family activation and engagement in their own care.
As appropriate to the population, partners with patient and family to develop SMART (specific, measurable, attainable, relevant, time-bound) goals.
Assists in the development, procurement, and adoption of patient self-management educational resources.
Identifies potential barriers to learning and/or to the optimal delivery of care.
Reports abnormal findings to the responsible provider/care team, and collaborates to develop a plan.
Independently manages CM caseload according to department expectations.
Ensures timely completion of tasks and documentation related to MCO, regulatory and contractual requirements.
Partners with identified at-risk patients throughout the diagnosis, treatment and follow-up in order to deliver continuity of care.
Anticipates the needs of the patient, recognizes and responds to changes in a patient’s status and determines priorities of patient care based on essential patient needs.
Coordinates patient information and communication between and among the patient/family, the referring/accepting facilities and physicians, community caregivers (as applicable) and other members of ACM to ensure smooth transitions of care.
Coordinates referrals to other internal AAH departments and/or external community resources as necessary.
Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served.
Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures.

Benefits

Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance
Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program