Care Manager - LPN

CareAbout

11d•$26 - $38•Hybrid

About The Position

The Care Manager (CM) will work on a multidisciplinary healthcare team in a primary care / telephonic setting, focusing on coaching and coordination of care for patients needing navigation and follow up. The CM will identify the needs of patients at risk and assist the providers to develop processes for managing the member population’s preventative care, transitions of care, and or disease management. This person will promote patient-centered care, working with primary care providers and medical home team members. The CM is a key role in the care coordination of patients attributed to value based contracts. Hybrid Schedule: 3 days in office (33 Newton Sparta Road Newton NJ) and 2 days remote following probationary period.

Requirements

Graduation from an accredited and approved nursing program
Active LPN license in good standing required.
Willing to obtain Certified Case Management (CCM) certification once qualified.
1 to 3 years of direct patient care experience as an RN or LPN required.
Working knowledge of the following required:
Principles of utilization management; Case/care management principles; Health care contracts and benefit eligibility requirements; Hospital structures and payment systems.
Basic PC skills (MS Word/Outlook/PPT/Excel).
Ability to use independent judgment and to manage and impart confidential information.
Ability to analyze and solve problems; requires details, data and facts that must be analyzed and challenged prior to making decisions.
Strong communication and interpersonal skills.
Ability to clearly communicate medical information to professional practitioners and/or the public.
Excellent organization, prioritization, follow up, analytical and time management skills with ability to handle multiple priorities and deadlines.
Good interpersonal skills, sense of urgency, being proactive and ownership for one’s work.
Dependable, with strong work ethic and extremely high degree personal integrity.
Ability to deal with multiple interruptions on a continual basis that must be met with a friendly exchange with others.
Ability to develop and implement new approaches to improve processes, procedures, or the general work environment.
Ability to review critical issues, effectively solve problems and create action plans.

Nice To Haves

Care/Case Management experience preferred.
Experience in acute inpatient, rehabilitation, sub-acute, skilled facility, home care, ambulatory care management, or managed health plan.

Responsibilities

Develop constructive relationships with internal Continuum population health team members, participating providers, and community resources.
Work to develop systems, processes, and initiatives to engage patients in relevant case management activities necessary to promote wellness and care at the right place and time.
Confirm care is coordinated with home care agencies, specialists, or other resources needed.
Monitor to ensure follow-up primary care visits are obtained within 24 hours of hospital discharge.
Conduct follow-up procedures to verify that initial patient assessment and post-visit consultation includes a comprehensive medical, psychosocial, and functional assessment of the patient.
Ensures assessments are in order and completed as identified by the patient’s provider.
Communicate with and coach patients to ensure they are aware of discharge instructions, have necessary prescriptions, access to medications, and understand how to take medications, including recognizing adverse events as per their care givers instructions.
Verify that appropriate home care, hospice care, and other ancillary services (DME, infusion services etc.) are in place and are being delivered as directed by the care team.
Coordinate necessary referrals and authorizations within care management areas.
Facilitate the information flow between hospital, long-term care, specialists and home health representatives and the care team.
Work with physician and office staff to help identify high risk, high need, and potentially high-cost patients.
Assist physicians and care team in implementing processes for best practices for preventive services, chronic care, and disease management.
Work collaboratively with physicians and the care team to ensure patient adherence to medical plan of care.
Establish plans which include appropriate preventive and disease-specific screenings, interventions, and treatment goals [e.g., self-management goals and contract schedules].
Coordinate care and communicate with multiple providers, internal and external to the practice.
Identify and utilize cultural and community resources.
Verify that members are screened for behavioral health concerns (depression / substance abuse) and are receiving appropriate screening and behavioral health interventions.
Facilitate any necessary follow-up behavioral health needs with local behavioral health providers.
Attend required training and collaboration sessions [i.e., learning sessions, care management meetings, and practice team meetings] as scheduled.
Assess patient needs and develop a plan of action to address needs in collaboration with the primary care physician.
Provide and facilitate open communication, regarding patient status, with physicians and office staff.
Obtain records from other physicians/labs/diagnostic centers as requested by the physicians and as needed for care coordination efforts.
Performs miscellaneous job-related duties as assigned