Care Manager

SUMMARY OF DUTIES: Freedmen’s Medicine is a small home health agency with just over 10 employees. We have established a hybrid medical practice model that specializes in transitional and in-home patient care for chronically ill patients. To be successful, the Chronic Care Manager requires a comprehensive knowledge of chronic care management to include knowledge of chronic diseases such as chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, behavioral health, and substance abuse disorders. The Chronic Care Manager functions as the subject matter expert (SME) in all aspects of the provision of chronic care management (CCM), this includes adherence to identified timelines for initial and follow-up actions and services. S/he works in collaboration with the Clinical Lead and other members of the team to maximize productivity, maximize billing, meet required deadlines, and ensure that critical patient issues are addressed in a timely manner.PRIMARY RESPONSIBILITIES: Acknowledges acceptance of identified patient load and advocates for their patients and communicates with other healthcare providers to accurately update documents and schedule appointments. Validates enrollment of chronically ill patients based on provider requests. Coordinates continuity of patient care with primary care providers, specialty care providers and community resources to affect positive health outcomes in an effort to decrease readmission rates. Conducts minimum of one 20-60 minute session of telephone or in-person counseling and education per month to each care management patient on roster and ensures compliance with established time frames for specific services and functions. Complies with documentation requirements of the Care Management program by carrying out the care plan with the patient, family/caregiver (s) and providers and records results in the Electronic Health Record (EHR) and other related systems. Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, facilitates changes as needed, and ensures the Care Management supervisor is aware of significant changes in patient’s condition and disposition. Work closely with community resources and providers to manage the patient’s day to day needs involving: symptom control, medication management, and provide patient and family education. Provides patient health counseling, education and instruction and educates patient and family/caregiver(s) about relevant community resources. Supports patient self-management of disease and behavior modification interventions. Provide weekly updates to the clinical team on adherence to identified key performance indicators and supporting metrics and communicates plan to mitigate performance issuesEXPERIENCE and EDUCATION: • Associate or bachelor’s degree is a plus • 2+ years’ experience with patience care management,This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.