The Clinical Manager is responsible for overseeing the continuity of patient care in the ALIGN-CARE Geriatric Surgery Co-Management program. This program focuses on patients aged 65 years or older who are frail, community-based, and considering surgery. The program is expected to start with approximately 50 patients and grow to 200-250 within the second year. Patients will be initially seen in an outpatient setting for assessment of surgical risks and to develop care plans for health optimization prior to surgery. The Clinical Manager will be involved in team-based initial assessments, follow-up tracking, and providing education and counseling pre-hospitalization, peri-operatively, and post-operatively. Post-discharge, the Clinical Manager will follow up with patients via telephone and transitional care management workflows to ensure optimal post-operative care, aiming to reduce unnecessary emergency room returns or hospitalizations. Patients may come from any part of the Mount Sinai Health System, with care provided at both Mount Sinai Hospital and Mount Sinai Morningside. The Clinical Manager will require access to both hospital domains for telephonic, video visits (virtual), and occasional in-person outpatient care. The role reports to the Geriatrician program director, Dr. Stephanie Chow, and collaborates with an interdisciplinary team including an administrative associate, nurse practitioner, care coordinator, and social worker within the Brookdale Department of Geriatric and Palliative Care Medicine. The Clinical Manager will not be expected to have repartees but may work with medical trainees. Key responsibilities include tracking patients throughout the program (Pre-, Peri-, Post-operatively) in a secure database, documenting clinical encounters in EpicCare EMR, providing patient and caregiver instruction and coaching, and communicating with surgical teams and extended care teams as needed. Additionally, the Clinical Manager will oversee the collection, compilation, and analysis of clinical program activity data for performance evaluation, generating biweekly and monthly reports on program progress and performance for stakeholders, and facilitating program growth, research, and development.
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Job Type
Full-time
Career Level
Mid Level