Case Manager

Appalachian Mountain Health • Sylva, NC

17d

About The Position

Job Description:Title: Case Manager
Category: Non-Exempt
Appalachian Mountain Health (AMH) is a Federally Qualified Health Center (FQHC) that provides comprehensive primary care to low-income, medically underserved and uninsured populations. AMH’s mission - to provide culturally competent, high quality healthcare to the medically vulnerable population in western North Carolina - is rooted in a primary care and preventive services medical home model with fees for services adjusted on the basis of a patient’s ability to pay.

ESSENTIAL DUTIES & RESPONSIBILITIES
Responsible for contacting and monitoring patients after they are discharged from the hospital or Emergency Department, ensuring they are following their treatment plan, accessing necessary services, and addressing any issues that may arise during their transition back home; essentially coordinating their post-discharge care and advocating for their needs.
This includes:
· Transitions of Care Management (TCM). Identify patients who have recently been discharged from the hospital and who qualify for TCM services. Complete the TCM assessment, perform medication reconciliation, ensure hospital records are obtained, and ensure hospital follow-up appointment is scheduled appropriately, and communicate essential transition information with key stakeholders across the continuum of care
· Outreach to patients recently seen in the Emergency Department, ensure hospital records are obtained, and ensure hospital follow-up appointment is scheduled appropriately
· Pre-chart information from the patient’s Discharge Summary into the scheduled provider’s note, giving the provider easy access to important information about the patient’s hospital stay or ED visit.
· Facilitate team discussions and coordinate care for patients
· Provide education to patients, families, and caregivers or refer to appropriate clinical resources
· Adhering to mandatory reporting guidelines for abuse and neglect
· Actively participating in the Value-Based Care team
ADDITIONAL DUTIES (as needed)

KNOWLEDGE & SKILLS
· Excellent interpersonal skills in one on one, group, and community settings
· Ability to plan, schedule and coordinate
· Effective management of multiple duties and responsibilities
· Sound leadership and judgment
· Excellent communication skills in person, on the phone and in written communications
· Flexibility in a rapidly growing and changing work environment

Requirements

• Associate Degree in Social Work, Nursing, Health Education, Medical Assisting, or other healthcare discipline
• Excellent written and verbal communication skills
• Proficient with medical office technology and equipment, including computers, copiers,
• scanners, fax machines, and phone systems, as well as MS Excel/Word/Outlook,
• Electronic Health Record systems and automated medical scheduling and billing
• programs.
• At least one year of experience in a primary care or public health setting functioning at the full extent of her/his training.

Nice To Haves

• Bachelors Degree in Social Work, Nursing, Health Education, or other healthcare discipline
• Experience with PM systems or EMR
• Experience working with racially and ethnically diverse populations, low-income populations and people experiencing homelessness
• Prior work in performance or quality improvement
• Fluency in Spanish, Russian, or Ukrainian.

Responsibilities

• Contacting and monitoring patients after they are discharged from the hospital or Emergency Department, ensuring they are following their treatment plan, accessing necessary services, and addressing any issues that may arise during their transition back home; essentially coordinating their post-discharge care and advocating for their needs.
• Transitions of Care Management (TCM). Identify patients who have recently been discharged from the hospital and who qualify for TCM services. Complete the TCM assessment, perform medication reconciliation, ensure hospital records are obtained, and ensure hospital follow-up appointment is scheduled appropriately, and communicate essential transition information with key stakeholders across the continuum of care
• Outreach to patients recently seen in the Emergency Department, ensure hospital records are obtained, and ensure hospital follow-up appointment is scheduled appropriately
• Pre-chart information from the patient’s Discharge Summary into the scheduled provider’s note, giving the provider easy access to important information about the patient’s hospital stay or ED visit.
• Facilitate team discussions and coordinate care for patients
• Provide education to patients, families, and caregivers or refer to appropriate clinical resources
• Adhering to mandatory reporting guidelines for abuse and neglect
• Actively participating in the Value-Based Care team

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree