ICP Community Care Manager / Clinical Integration

Hartford HealthCare•Wethersfield, CT

32d

About The Position

Work where every moment matters. Every day, more than 40,000 Hartford HealthCare colleagues come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut's most comprehensive healthcare network. The creation of the HHC System Support Office recognizes the work of a large and growing group of employees whose responsibilities are continually evolving so that we and our departments now work on behalf of the system as a whole, rather than a single member organization. With the creation of our new umbrella organization we now have our own identity with a unique payroll, benefits, performance management system, service recognition programs and other common practices across the system. Position Summary: The ICP Community Care Manager is a healthcare professional position, working as a member of the ICP Community Care Management team. The ICP Community Care Manager facilitates transitions as patients move from one level of care to another, ensuring that uninterrupted quality care, as well as providing ongoing education and diseased management for ICP attributed patients with chronic conditions. They are responsible for providing support and performing duties in a manner that ensures effective and efficient customer service and patient care. This position is ideal for someone with a minimum Master of Social Work or minimum Bachelor of Science in Nursing with a healthcare professional background that is passionate about transforming healthcare and assisting patients in meeting their health goals.

Requirements

Minimum: Master of Social Work (MSW), or Bachelor of Science in Nursing (BSN)
Minimum: Accredited Case Manager (ACM) or Commission for Case Manager (CCM) Certification
Minimum: Able to read, speak, write English
At least five years of experience working in a healthcare setting and at least two years of experience in case coordination/care management
A passion for helping vulnerable populations by managing patients across the care continuum
Knowledge of chronic disease education and support of complex patients
Awareness in supporting patients on accessing community resources
Knowledge of medical terminology, as well as ACO, payment models, utilization management and healthcare reform topics
Willingness to develop new skills and ability to receive feedback
Positive, customer-focused approach
Proven ability to work effectively independently as well as in a team environment
Must be comfortable and flexible with ambiguity and change processes
Excellent written and verbal communication skills
Strong organization skills and attention to detail
Establishes and maintains effective work relationships
Displays courtesy and helpfulness when interacting with all internal and external customers
Proactively takes action to achieve goals beyond what is required or assigned
Adheres to HIPAA requirements
Adheres to Hartford Healthcare policies and standards of service, as well as those of practices being supported
Physical abilities to include sitting and standing for prolonged periods
Must attend and pass examination for Mental Health First Aid Certification within first year of hire

Nice To Haves

Preferred: Licensed Clinical Social Worker (LCSW), Social Work Licensure or Master of Science in Nursing (MSN)
Preferred: Mental Health First Aid Certification within 1st year of hire
Preferred: Ability to communicate in other languages highly desirable

Responsibilities

Performs transition of care services for ICP attributed patients admitted to acute inpatient settings, skilled nursing facilities and other post-acute facilities
Participates in discharge planning meetings throughout patient's inpatient acute/Skilled Nursing Facility (SNF)/Long-Term Acute Care Hospital (LTACH) stay, as appropriate
Partners with inpatient care coordination team to address barriers to discharge including: Social Determinants of Health needs, other biopsychosocial related needs and/or healthcare related barriers, while also providing timely communication back to the patient's primary care provider
Collaborates with other HHC system partners upon patient's discharge from acute inpatient, skilled nursing facility and other post-acute facility setting to the community
Partners with Skilled Nursing Care Coordinators, Resource Coordinators, ICP Clinical Pharmacists, Primary Care Behavioral Health Clinicians and homecare partners to support patients across the care continuum
Reviews and identifies at risk patients (ED utilization, high risk score, care gaps, etc) for proactive outreach and longitudinal care management
Collaborates with patient, caregiver, providers and additional care team members to develop longitudinal plan of care including development of a care plan, appropriate referrals and community supports
Identifies resources within HHC system and larger community to address patient care needs
Provides education for patients, families, community, and other professionals regarding disease prevention, impact of illness and advocacy for benefits and health maintenance
Participates in continuous improvement opportunities through workgroups, collaborative pilots and system initiative councils. Contributes to ongoing development of the care management model across the continuum through valuable input and constructive feedback.