Case Manager - Physician Practice coordinates the overall interdisciplinary plan of care for assigned patients in a physician practice setting. Acts as a liaison between patient/family and healthcare personnel to ensure necessary care is provided and that patient is making progress towards treatment goals. Being a Case Manager - Physician Practice typically requires a bachelor's degree. Must be a registered nurse(RN). Additionally, Case Manager - Physician Practice typically reports to a physician/department manager. Case Manager - Physician Practice's years of experience requirement may be unspecified. Certification and/or licensing in the position's specialty is the main requirement. (Copyright 2024 Salary.com)
Counselor/Social Worker/Psychology Graduate/Case Manager
SUMMARY:
Provides support for designated clients/beneficiaries which includes coordinating an array of services designed to improve the health of high needs, high risk clients/beneficiaries. Care coordination responsibilities will include assessment, care planning and monitoring of client status, and implementation and coordination of services. Provides support to clients/beneficiaries for effective care transitions, improved self-management skills and enhanced client/beneficiary-provider communication. Will facilitate interdisciplinary consultation, collaboration and care continuity across care settings.
ESSENTIAL FUNCTIONS:
· Engages clients in care coordination activities designed to promote improved utilization of health care services, including the creation and ongoing maintenance of a patient-centered, goal oriented Health Action Plan (HAP).
· Assesses activation level for self-care through use of the Patient Activation Measure® (PAM®).
· Provides evidence-based health assessments and screenings such as; BMI, PHQ-9, Katz ADL, GAD-7.
· Provides transition support services, generally based on the Coleman model of Care Transition Intervention.
· Works with supervisors and other healthcare providers, hospital discharge planners, skilled nursing facility staff, and staff at the client’s health home to implement services and analyze the disposition of cases.
· Coaches the client/beneficiary to build confidence and competence in four conceptual areas, or “pillars”: medication self-management, use of a patient-centered health record, primary care and specialist follow-up, and knowledge of red flags of their condition and how to respond.
· Performs facility visits, home visits, and follow up telephone calls to develop critical coaching relationships, to empower clients/beneficiaries to take an active and informed role in their discharge planning and introduce them to the patient-centered Personal Health Record.
· Tracks coaching-related metrics and reports on intervention progress.
· Coordinates follow-up activities and referrals with other programs including the Family Caregiver Support Program and AAADSW/HCS Medicaid Case Management.
· Coordinates and communicates regarding the client’s/beneficiary’s post-discharge status with all involved health care providers including, but not limited to: primary care, mental health, specialty care, and pharmacy.
· Identifies and addresses barriers to overcome impediments to accessing health care and social services.
· Provides referrals and advocacy for clients/beneficiaries and their caregivers to community long term services and supports, which includes family caregiver programs, nutrition programs, in-home care and case management.
· Provides teaching about self-management of the client’s/beneficiary’s chronic health condition and provides resource links to ongoing chronic disease self-management support services.
· Develops and maintains complete and concise client/beneficiary files in compliance with policy to appropriately document activities performed for the client/beneficiary and all elements required for specific programs.
· Maintains all required documentation related to services provided and conforms to monthly deadlines.
· Participates in staff meetings, public education and provider training sessions, as appropriate.
· Develops and maintains relationships with community agencies and organizations that have the potential to provide resource support to the program or individuals.
· Prepares correspondence, memos, and client related written materials, as appropriate.
· Participates in continuing education and training programs.
· Works collaboratively with multi-disciplinary teams involving nurses, case managers and case aides.
· Attends required meetings and trainings.
Knowledge, Skills, and Abilities:
· Ability to travel to and from client’s homes and other community agencies which might not be ADA accessible.
Minimum Qualifications:
· Training in Coleman CTI or other coaching modality is desired.
· Experience working on cross disciplinary, cross-organizational teams.
· Experience meeting and working with people in homes and other medical and community settings.
· Possession of a valid driver’s license and minimum state-required vehicle insurance and have use of reliable transportation.
Job Types: Full-time, Part-time
Pay: $24.00 - $30.00 per hour
Benefits:
Schedule:
Application Question(s):
services and behavioral sciences; or
Education:
Experience:
Shift availability:
Ability to Relocate:
Work Location: In person
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