Care Manager - Home Health

Job Requirements

The Care Manager is assigned a panel of patients to manage in collaboration with primary care providers and members of the care management team. The Care Manger will educate the patients on self-care, properly accessing healthcare services, and will utilize motivational interviewing techniques. The Care Manager is also responsible for coordinating care and community services to obtain desired health outcomes, decrease cost of care, improve quality of life, and provide extraordinary patient care in the process. The Care Manager utilizes evidence-based medicine, data analytics and innovation in implementing care management principles to meet patients’ and their families' needs.

Additionally, the Care Manager must be flexible and adapt to changes in the work environment, manage competing demands, change the approach/method to best fit the situation and be able to cope with delay or unexpected events. It is essential to take responsibility, keep commitments and complete tasks on time. Also, volunteer readily, take independent actions and ask for and offer help when needed.

Minimum Requirements

Education

• Graduate of an accredited school of nursing, Bachelor’s Degree (other than nursing) with an ADN or an accredited school of Social Work (MSW)

Experience

• 3-5 years of healthcare experience in outpatient setting, population health, social services, home health, or other health care setting OR 1-3 years Care Management experience (Care Coordination, Transitions of Care, or Outpatient Case Management)

License/Registration/Certifications

• Active SC Registered Nurse license if RN
• Active SC Social Worker license if Social Worker
• Valid US driver’s license with driving record with active and up to date SC car insurance

Preferred Requirements

Preferred Education

• Bachelor of Nursing (BSN)
• Licensed Independent Social Worker for Clinical Practice (LISW)

Preferred Experience

• 6-8 years of experience in outpatient setting, population health, social services, home health, or other health care setting.
• Motivational Interviewing
• Epic Experience
• Health coaching
• Chronic Condition Management
• Home Visit Experience
• MS Office
• Motivational Interviewing

Preferred License/Registration/Certifications

• Accredited Case Manager (ACM)

Core Job Responsibilities

• Provide telephonic or face to face outreach to engage members to assess their readiness to change by using motivational interviewing techniques to help members identify and overcome barriers that often include behavioral risk factors, such as smoking, poor health literacy, sedentary lifestyle, elevated BMI, and poor disease management.
• Coordination of referrals and transitions of care from one provider to another or from one care setting to another.
• Provide medication adherence and chronic condition education with patients and family members.
• Facilitation and/or procuring timely access to appointments and services required by patient
• Patient and Family/Caregiver education.
• Perform facility visits, not limited to; inpatient, home, office/clinic, SNF/Rehab, within a designated time frame.
• Evaluation of effectiveness of care plan with Complex Case Review as Requested
• Documenting and evaluating observed patient behaviors regarding medication adherence, ADL’s, social determinates of health, and their engagement in their own health care plan outlined by their specialist and primary care physicians.
• Encouraging patient directed goals and action items correlated with observed patient behaviors to impact chronic condition education, medication adherence, and the completion of Physician lead care plans.
• Assesses patient and patient's family on ability to self-engage and develops individualized patient and patient's family education plan focused on development of self-management skills based on SRHS departmental standard of care protocols.
• Identifies patients with special needs and facilitates integration of primary care with specialty and other services such as behavioral, social determinates of health, and community services where appropriate.
• Plans, develops, assesses, and evaluates care provided to specific patient populations, and engages team of care transition coach and care coordination to divide workload among team where appropriate.
• Performs analysis of the effectiveness and appropriateness of patient care plan; and modifies care plan based on assessment and evaluation.
• Communicates clear, complete, accurate, and timely documentation in a health record to ensure that all those involved in a client's care have access to necessary information to plan and evaluate their interventions.
• Updates plan of care to ensure all care team members have timely information regarding the patient's status.
• Ensure the proper handling of patient records to ensure compliance with patient health information applicable to the preservation, accuracy, and completeness of communication and/or retention of patient information, meeting all HIPAA regulations and the HITECH Act provisions as required by law
• Must meet productivity and documentation standards set by direct supervisor.
• Ability to maintain departmental patient caseload requirements as determined by internal payor strategies and/or leadership.

All other duties as assigned.