About this role
The Care Manager effectively manages outpatients to support management of patients with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care to prevent re-admissions. Ensures that Members’ medical, environmental and psychosocial needs are optimized through the continuum of care. Identifies appropriate patients for care management and performs outbound calls to assign high risk or chronic care managed patients Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment Develop Initial Care Plan (ICP) by conditions identified in HRA, patient assessment, medical records authorizations/referrals, primary care physician, member and Interdisciplinary Team Sets patient prioritized self-management goals. Create cares in the care management platform for each patient under care management with appropriate documentation including but not limited to; cognitive, functional, ADL, environmental factors, psychosocial, medical and benefits etc Coordinates care plan and/or assessment findings with health plan care managers, as appropriate Manages a panel/caseload of 75 - 100 chronic and high-risk patients in collaboration with Nurse Practitioner, Pharmacist, PCP, specialists and other ICT members. Meets assigned/expected patient contacts daily to assess and coordinate care. Interfaces with Medical Director and attends and participates in Interdisciplinary Rounds Collaborates and coordinates care with health plans, Community Based Programs, Palliative Care and Behavioral Health providers as appropriate. Collaborates with patient’s family and physicians for seamless coordination of care and services Monitors and evaluates effectiveness of the care management plan and modifies as necessary to meet health plans and national standards (i.e., NCQA requirements) for turn-around-time for assessments, care plans and IDTs Other duties as assigned