Manager-Team Lead Care

Northeast Georgia Health System•Gainesville, GA

1d•Hybrid

About The Position

The RN Lead Care Manager will participate in care management committees and work on special projects related to care management, as needed. The RN Lead Care Manager will assist the HP2 network providers in applying systems, science, incentives, and information to improve medical practice and patient care, eliminate duplication, and reduce the need for medical services by helping patients and their support systems in managing medical conditions more effectively. The RN Lead Care Manager will provide telephonic care and case management to members as part of a multidisciplinary care team. The RN Lead Care Manager will offer members of HP2 health and disease education and empower them to actively participate in their care. Other duties of the RN Lead Care Manager include, but are not limited to, implementation of policies and procedures, to support care management programs and promote collaboration, supervise and provide support to ensure services reach the target populations, assist with developing and facilitating training for HP2 Care Management staff, serves as a liaison between the organization and community partners, to advocate for patients, lead interdisciplinary team meetings, to identify concerns/issues and implement strategies and interventions, consultation with members on their medications and durable medical equipment, review member care plans, address home care needs, and connect members to community resources; collaboration with primary care physicians and other providers to ensure there are no gaps in care; collaboration with members, providers, and care givers to ensure positive care outcomes during care transitions. The RN Lead Care Manager will provide evidence-based services to assist patients in achieving an optimal level of wellness and improve coordination of care while providing cost effective, non-duplicative services. Care management services may be provided in a variety of settings including in-person, face-to-face encounters, by telephone, or electronic encounters such as telehealth visits. Primary areas of focus will include management of patients with multiple chronic conditions, including those complex health care needs identified by HP2 and managing transitions of care.

Requirements

Current Georgia RN license required.
Current BLS certification required or must be obtained within 30 days of hire.
Associates Degree
Two years minimum experience providing care management services within a health plan, health system, or home health, care management required.
High energy and ability to function effectively in a dynamic work environment.
Strong organizational and interpersonal skills; able to work effectively in a team environment.
Must be able to multi-task and prioritize on a daily basis.
Must be flexible and adaptive to a changing environment.
Must be proficient with computers, have the ability to type and talk simultaneously, and have excellent interpersonal and customer service skills, including telephone etiquette.
Excellent written and verbal communication skills.
Strong analytical and problem-solving skills; ability to review reports and complete data validation.
Excellent understanding of medical terminology and disease states.
Able to interpret complex regulations.
Maintains current continuing education appropriate to care management.
Demonstrated expertise with Microsoft Excel and reporting databases.

Nice To Haves

Case Management Certification
BSN
One year experience providing care management within a primary care setting is preferred.

Responsibilities

Participate in care management committees and work on special projects related to care management.
Assist HP2 network providers in applying systems, science, incentives, and information to improve medical practice and patient care.
Provide telephonic care and case management to members as part of a multidisciplinary care team.
Offer members of HP2 health and disease education and empower them to actively participate in their care.
Implement policies and procedures to support care management programs and promote collaboration.
Supervise and provide support to ensure services reach the target populations.
Assist with developing and facilitating training for HP2 Care Management staff.
Serve as a liaison between the organization and community partners.
Advocate for patients.
Lead interdisciplinary team meetings.
Identify concerns/issues and implement strategies and interventions.
Consult with members on their medications and durable medical equipment.
Review member care plans.
Address home care needs.
Connect members to community resources.
Collaborate with primary care physicians and other providers to ensure there are no gaps in care.
Collaborate with members, providers, and care givers to ensure positive care outcomes during care transitions.
Provide evidence-based services to assist patients in achieving an optimal level of wellness and improve coordination of care.
Provide cost effective, non-duplicative services.
Manage patients with multiple chronic conditions, including those with complex health care needs.
Manage transitions of care.
Collaborates with providers in promoting the delivery of high quality medically appropriate care and services using fiscally responsible strategies.
Uses the nursing process to assess, plan, implement, and evaluate patient care and the use of resources.
Assists in the development, implementation, and analysis of a process for providing outreach to patients with identified care opportunities including, but not limited to, non-compliance, and maintaining clinical markers (e.g., blood pressure, HbA1c) within normal range.
Monitors the quality of care to ensure all aspects of services are safe and appropriate.
Make outbound calls to assess member’s current health status.
Development of a patient centric care plan.
Provide patient education to assist with self-management.
Identify gaps or barriers in treatment plans.
Educate members on disease processes.
Coordinate care for members.
Make referrals to outside sources.
Coordinate services such as home health, DME, as needed.
Tailors interventions that are multi-faceted, improve quality and cost effectiveness to meet the patient's need while respecting the patient's role as a decision maker in the care planning process.
Effectively uses tools/strategies that include, but are not limited to: evidence-based guidelines and practices, interactive care plan developed based on patient-set priorities where applicable, collaboration with multidisciplinary care teams, meet medical home (PCMH) requirements, physical/behavioral health integration, and patient self-management education and training.
Effective and timely adherence to disease specific, evidence based guidelines for all chronic conditions as well as preventative and curative care measures.
Improves overall patient care metrics as set by evidence practice medicine and recommended guidelines that are widely set for disease state/conditions that result in most health care expenditures as revealed in CMS chronic conditions literature and/or HP2 cost data (i.e., heart failure, diabetes, hypertension, COPD/Asthma, pneumonia, depression and stroke).
Focus should minimally cover those patients with 4 or more chronic conditions.
Effectively and timely inform patients about their care planning and facilitate interaction among applicable care team members through application-based secure messaging, assessments, care planning and associated activities, and education.
Maintains awareness and understanding of patient resources from the NGHS, NGPG, the community, and payors to support care management, care coordination, and transitional care.
Anticipates needs of the patient population, identifying and developing programs to support care management, patient education and self-management activities.
Demonstrates reduced emergent/urgent care utilization and acute care readmissions, improved medication compliance, and adherence to diet/prescription regimens managed patients.
Assists in building an evidence base in terms of what works for complex and special needs populations through careful and consistent evaluation, measurement, testing, and analysis of interventions intended to improve quality and efficiency.
Ensure that discharged patients receive the necessary services and resources, including medication reconciliation.
Maintains current awareness and understanding of quality measures (e.g., HEDIS, Direct Contracting, pay for performance) and measures related to efficient utilization and cost.
Participates in the development/review/revision of standard work and related policies and/or procedures for Care Manager services.
Assists in identifying opportunities for system-collaboration, patient education materials, and/or other programs designed to meet patient population needs.
Coordinate care management efforts with network embedded care managers to ensure efficient collaboration and effective handoffs.
Assists in the identification of population health circumstances where standing orders do not exist, or exist but are not consistently utilized, for improving patient care outcomes.
Attends meetings with payors when patients being managed are discussed.
Encourage members to make healthy lifestyle changes.
Document and track findings in a computerized system.
Other duties as assigned.