Care Manager
Location: Lewes, Delaware
Description: Aledade, Inc. is at present recruited Care Manager right now, this position will be ordered in Delaware. For detail informations about this position opportunity please read the description below.
This position is responsible for the success of the Chronic Care Management (CCM) program within independent primary care practices that are part of the Aledade Delaware Accountable Care Organization (ACO). The qualified candidate is a proactive and self-motivated clin ical care manager who will identify and enroll appropriate patients in the program and work in concert with the patient's primary care team and ACO experts to provide direct telephone-based care management services addressing comprehensive challenges that impact the health of the patient. The successful CCM-enrolled patient will become activated in self-managing their health, will achieve high levels of satisfaction with their healthcare team, and will experience reduced unnecessary healthcare utilization before graduating from the program. The Candidate will participate in and support other ACO initiatives within the practice as needed.
Candidates should reside within or near Southern Delaware and should anticipate daily travel within the state.
Responsibilities:
- Review patient data within the ACO population health tool and Electronic Health Record (EHR) system to identify and enroll appropriate high-risk patients in care management services. < li> Work in partnership with primary care providers and each patient to establish a comprehensive goal-driven care plan.
- Apply your clinical knowledge to address the patient's chronic disease, psychosocial, behavioral health, hospital utilization, pharmaceutical, and social determinants of health barriers.
- Coordinate care by serving as the advocate and resource for the patient, their family and their providers, building effective relationships in the community, (i.e., local hospitals, home health agencies, senior community services agencies, etc.) across the continuum of care to strengthen care coordination and safe care transitions across care settings.
- Comply with billing requirements and the needs of each primary care practice when documenting care plans and care management services provided. Develop competency with various EHR systems.
- Leverage ACO methodology and care management toolkits to provide telephone-based support to patients enrolled in the chronic care management program, ensuring that patients are self-activated and achieving their healthcare goals, health outcomes and quality are improved and unnecessary utilization declines.
- Identify and dis-enroll patients when goals have been achieved.
- Liaise with ACO field team members and care management experts to ensure care management initiative aligns with other ACO initiatives and goals and care management barriers are addressed using a team-based approach.
- Develop and deliver care manager training on population health tools, chronic care management guidelines, and effective care management techniques through regular conference calls and in-person training events.
- Aid in the development of new or improved ACO systems, tools and workflows to ensure the needs of ACO Care Managers and patients are met efficiently.
- Perform components of the Medicare Annual Wellness Visit as requested such as falls risk screen ing, depression screening, advance care planning, and other preventive services in the primary care provider office setting.
- Participate in additional ACO activities within the practice as required.
Qualifications:
- A Registered Nurse, a Licensed Practical Nurse (LPN), or an experienced Medical Assistant with demonstrated skills and knowledge.
- At least 3 years of experience, preferably in case management, community public health, utilization management, or care coordination across multiple settings and with multiple providers
- Knowledge of patient activation, motivational interviewing, chronic disease self-management, goal-driven care planning a plus
- Excellent computer skills and willingness to learn new software applications. Electronic health record experience and population health management tool experience a plus
- Familiarity with healthcare entities operating within the State
- Experience providin g care to vulnerable populations
- Understanding of value-based healthcare, the ACO model, and population health fundamentals a plus
- Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion
- Strong work ethic built on a foundation of productivity, collaboration and teamwork
- Ability to manage multiple projects and activities with minimal supervision
- Demonstrated knowledge of continuous quality improvement techniques
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If you were eligible to this position, please send us your resume, with salary requirements and a resume to Aledade, Inc..
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This position will be opened on: Thu, 26 Apr 2018 12:54:14 GMT