Care Connection Case Manager

Carilion Clinic•Roanoke, VA

1d•Onsite

About The Position

The Care Connection Case Manager provides care management for specific patient populations, utilizing clinical expertise, communication and problem-solving skills to achieve optimal clinical and resource outcomes. Promotes cost-effective care by minimizing fragmentation, maximizing coordination and facilitating patient/family movement through the system. Applies protocols when appropriate and facilitates referrals, providing linkages to health and wellness resources across the health care continuum. Promotes interdisciplinary collaboration and teamwork to progress the plan of care. The Care Connection Case Manager provides care management for specific patient populations, utilizing clinical expertise, communication and problem-solving skills to achieve optimal clinical and resource outcomes. Promotes cost-effective care by minimizing fragmentation, maximizing coordination and facilitating patient/family movement through the system. Applies protocols when appropriate and facilitates referrals, providing linkages to health and wellness resources across the health care continuum. Promotes interdisciplinary collaboration and teamwork to progress the plan of care.

Requirements

Bachelor's degree in social work or related degree required.
Current RN license for the state of VA required, or LCSW preferred.
AHA BLS-HCP required in practices where the Care Coordinator provides direct patient care.
Must demonstrate knowledge and competency in the following areas: positive interpersonal oral communication skills; effective written communication skills; analytic skills; team player; courteous; ability to resolve complaints/problems; customer-focused philosophy of service delivery; ability; willingness to work as an integral member of a multi-skilled team.
Must demonstrate knowledge and competency in computer literacy; community and system resources; effective interpersonal relations; analysis and research methods.
Must have excellent communication skills both verbal and written to address individuals of varying educational levels.
Critical thinking and organization skills are important.

Nice To Haves

Graduation from an accredited school of nursing, bachelors degree preferred.
RN experience in a physician practice or clinic preferred.
Social work experience in health care setting preferred.
LCSW preferred.

Responsibilities

Must possess knowledge of growth and development appropriate to age group served and incorporate plan to meet needs into plan of care.
Performs patient/family data collection to assist in identifying individualized care management needs.
Works with all Care Coordinators to identify individual care management needs with Care Team to help identify those patients who need close follow up, resources, additional education, and support.
Coordinates plan of care and services, directing liaison activities to appropriately integrate the patient into the health care continuum.
Facilitates continuity of care using multidisciplinary collaboration and coordination of appropriate health care services and community resources across the care continuum.
Maintains effective communications with all disciplines.
Coordinates and manages all care transitions with a focus on comprehensive, accurate, and effective communication.
Engages and empower patient/ caregiver as an active participant in disease/ condition management.
Determines readiness/ willingness to change based on protocols and partners with patient/ caregiver/ care team in identifying goals, plan of action.
Identifies and tracks patient/ caregiver capacity for and confidence in self-care.
Supports patient/ caregiver in adopting healthy behaviors and promotes lifestyle changes.
Advocates for the patient and family throughout the entire episode of care.
Participates in Advisory Committee with medical consultant, Educational Consultant, Director, and parents to review processes, improvements, and educational needs for children with special needs.
Actively participates in quality improvement projects for our center.
Develop and maintain center policies and procedures that adhere to polices for care coordinators related to performance measures and industry standards.
Analyze centers data regarding level of care, caseloads, outcomes, etc. to identify trends, establish benchmarks, and along with program development and planning.
Implement quality improvement activities to ensure quality based on national case management standards.
Must be able to demonstrate the 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 through the life span, possess the ability to assess data reflective of the patient’s status, interpret the appropriate information needed to identify each patient’s requirements relative to his or her age and specific needs, and provide the care needed as described in departmental policies and procedures.
Must follow mandated regulations and policies.
Works with minimal supervision.