Outpatient Respiratory Therapist Care Manager, Per Diem

St. Luke's University Health Network•Allentown, PA

About The Position

The Outpatient Respiratory Therapist Care Manager assists the care team—including providers, medical assistants, nurses, and other clinical personnel—by coordinating care for patients on providers’ daily schedules and proactively managing care for patients who are not scheduled. The role supports preventive and chronic care for St. Luke’s Physician Group patients and serves as a primary conduit for advocacy, information, and referrals for patients and families. The position coordinates patient care plans, follow-up, education, and communication among patients, caregivers, healthcare facilities, and primary care teams. It also provides pulmonary disease and equipment education in patients’ homes and, when appropriate, during primary care appointments, and facilitates the Better Breathers Support group.

Requirements

Completion of an accredited Respiratory Therapist program.
Respiratory Therapist license in the appropriate state (Pennsylvania and/or New Jersey).
BLS certification.
Basic high-level understanding of Network contract obligations regarding care coordination.
Basic high-level understanding of governmental and commercial insurance plans and benefits.

Nice To Haves

CCM certification.
Training or experience in motivational interviewing and teach-back.
Ambulatory Care Management experience.
Bilingual English/Spanish skills.
Electronic health record documentation experience.

Responsibilities

Review provider schedules and patient charts to plan visits and coordinate current and future healthcare needs, with pre-visit planning completed one week in advance.
Monitor or schedule primary care follow-up within 48 hours of an emergency department visit, urgent care appointment, or hospital discharge.
Work with patients and their care teams to develop individualized treatment plans, including follow-up appointments, laboratory tests, and other care coordination.
Track specialist follow-up visits for complex patients.
Communicate with and coach patients about discharge instructions, prescriptions, medication access and use, and potential adverse events as directed by caregivers.
Facilitate information flow between hospitals, long-term care facilities, home health representatives, patients, and primary care teams.
Work with providers and clinical and clerical staff to identify high-risk, high-need patients.
Assist physicians and care team members in implementing best practices for preventive services, chronic care, and disease management.
Use the care management model, standards, and scope of practice for care coordination.
Use motivational interviewing and teach-back skills when interviewing and assessing patients.
Use the electronic health record, chronic disease registry, and other quality-reporting software to manage care for individual patients and populations.
Collaborate with providers and the care team to support adherence to medical plans of care, including preventive and disease-specific screenings, interventions, treatment goals, self-management goals, and service-utilization goals.
Identify and direct patients to appropriate cultural and community resources.
Provide in-home pulmonary disease and equipment education and assess for triggers that may exacerbate symptoms.
Provide pulmonary disease education at patients’ primary care appointments when appropriate.
Work with community health workers to educate patients about identifying symptom-exacerbating triggers in the home.
Facilitate the Better Breathers Support group.