Clinical Care Manager - Full Time

JOB SUMMARY: The Clinical Care Manager is responsible for the use of advanced nursing processes to identify high risk, acutely ill and patients with chronic disease. The role of this position is to improve health outcomes through enhanced coordination of care, patient education, and care team communication. This position is accountable for assessing, planning, coordinating, monitoring, evaluating, and managing services for patients and their families, to foster quality, continuity and appropriate utilization of health care resources throughout the continuum of care. The Clinical Care Manager facilitates the coordinated utilization of resources for maximization of health outcomes, patient/family satisfaction and financial outcomes. The Clinical Care Manager assists patients, families, and caregivers in securing necessary medications, equipment, community resources to facilitate health and overall wellness.  As a member of a multidisciplinary team, they consult with other health care team members to coordinate the services of preventive care and chronic disease management. 

• Provide targeted, proactive, relationship-based (longitudinal) care management to all patients identified as at increased risk, based on a defined risk stratification process and who are likely to benefit from intensive care management. 
  
• Provide short-term (episodic) care management along with medication reconciliation to a high and increasing percentage of empaneled patients who have a hospital admission/discharge/transfer 
  
• Provide short-term (episodic) care management along with medication reconciliation to patients in the highest risk category who have an ED visit 
  
• Communicates proactively with inpatient care teams including nursing, case management, and providers to facilitate smooth transitions to the next setting of care including primary care, specialty, home health, SNF, or assisted living.
  
• Promotes patient relationships with their primary care team, including providing assistance with establishing care with a primary care provider
  
• Provides clinical support and direct care management including patient education, goal setting, self–management support education and coaching for the care team’s top 5% highest risk patients
  
• Assesses, evaluates, and collaborates real time with the primary care providers, specialty care providers, and medical staff to create and confirm treatment goals, treatment plan, and clinical mileposts/goals used to progress forward and complete the individualized patient plan of care.
  
• Provide coaching and support with patients enrolled in care management; Revise treatment plan as needed; Adjust treatment per guidelines or per provider recommendations; Communicate treatment changes to PCP; Continue follow-up until patient meets goals or opts out of care management 
  
• Perform and document an intake assessment which includes obtaining and reviewing prior medical records, financial data, medical history, cognitive/verbal skills and needs and identifying barriers to accessing healthcare.
  
• Monitor patients frequently for changes in health status after initiation of a new medication, a hospitalization or recent decline in function. 
  
• Assess readiness for transition back to usual care team or more intensive level of care such as SNF
  
• Meets with patients, families, and caregivers as necessary and communicates the concerns, needs and barriers to care to the healthcare team in a timely, efficient, and accurate manner.
  
• Monitor lifestyle factors affecting health – such as tobacco use, substance abuse, nutrition and physical activity – and assist the patient with goal-setting to achieve behavioral change.
  
• Participate in regular staffing meetings focused on coordinating patient care within an interdisciplinary team, keeping the team updated on patients’ conditions and circumstances.
  
• Provide individual and family educational interventions including self-management goal-setting, counseling and training on the habits, lifestyle changes, supplies and tools necessary to manage their disease.
  
• Identifies potential financial barriers that would hamper or restrict progression through the individualized plan of care and makes appropriate referrals utilizing community resources or financial counseling to swiftly resolve barriers that restrict advancing the patient towards achieving optimal health. 
  
• Collects data essential to demonstrate quality indicators for clinic as pertaining to Merit Based Incentive Payment Systems (MIPS) and Comprehensive Primary Care Plus (CPC+).
  
• Using objective data, prepares a monthly update of work accomplishments that can be incorporated into the department’s quality report card. 
  
• Works in harmony and unison with all personnel within the department and throughout St Peter’s Health
  
• Promotes and assists in the smooth, efficient delivery of departmental services to patients and physicians.
  
• Completes and/or attends all required educational offerings annually.
  
• Demonstrates the ability to manage time, coordinate departmental functions and promote departmental and professional growth.
  
• Ability to use electronic software applications related to care management activities.  Operates copying machine, fax machine, and computer.  Handles AV equipment, materials, supplies, and patient belongings.
  
• Identify education/ training opportunities for providers, members, other health care workers and staff in support of health improvement initiatives
  
• Develop a strong understanding of “best practices” that can be shared with providers and care teams
  
• Act as a resource for clinic staff for problem solving, and disseminate educational materials and other resources 
  
• Manages development and implementation of care management activities
  

Essential Department and Organizational Functions

• Participates in continually improvement of care management processes
  
• Engages with and seeks out opportunities for community partnerships to advance the health and well-being of our patients and community
  
• Participates in performance improvement activities, as defined in the departmental plan.
  
• Perform other duties and projects as assigned
  

Knowledge, Skills and Abilities Required

• Knowledge of current practices in population health
  
• Ability to identify disparities and develop programs/intervention to help reduce them
  
• Knowledge of quality improvement/performance improvement tools 
  
• Competency with computer software programs, e.g. MS Outlook, Word, Excel, and PowerPoint
  
• Ability to maintain strict confidentiality of information
  
• Ability to work with clinics that serve the medically vulnerable
  
• Ability to set goals independently and prioritize work to balance competing deadlines in a professional manner
  
• Excellent customer service skills
  
• Excellent written and verbal communication skills
  
• Ability to manage multiple tasks
  

KNOWLEDGE/EXPERIENCE: Minimum of 3-5 years of health care experience. One or more year’s acute care nursing experience preferred. 

 EDUCATION: BSN/BAN or BS/BA required

LICENSE/CERTIFICATION/REGISTRY: RN licensed in the State of Montana required