Care Manager (Full-Time)

Requisition Number.

26-2173

Location/Store Number.

Warrensburg Health Center

Job Description/Requirements.

Proposed Schedule: 40 hours per week. Monday-Friday 8am-4:30pm.

Please Note: This position will be required to also travel to our Chester-Horicon, Bolton, Indian Lake, and North Creek Health Centers when needed.

The Care Manager is an integral part of the patient’s care team, enhancing primary care and providing an array of services to the patients of the network and support to the primary/specialty care settings. These services include but are not limited to: education, coordination, coaching, transfer of self-management skills, and addressing barriers (including socio-economic). Guidance will be provided to the patients and families for the purpose of improving the health of our populations, improving the quality of care provided and decreasing overall costs. Integrated comprehensive patient-centered care plans will be developed alongside the patient, resulting in improved patient outcomes. Care management activities will occur in health centers, via telehealth, and occasionally at the patients’ home, hospital or other community setting.

• Provide outreach, information, guidance, and education to the patient and/or family, primary care providers and other members of the care team for appropriate healthcare utilization, chronic disease (e.g. diabetes, hypertension) self-management skills, effective care transitions, assessment and elimination of barriers, including socio-economic barriers, promoting wellness and preventative care measures and enhanced patient-provider communication

• Develop individualized, goal-oriented, patient-centered care plans that promote positive outcomes and address physical health, mental health and socio-economic barriers

• Maintain an ongoing responsibility for assigned caseload by prioritizing referrals and activities according to intensity, needs and required follow-up

• Provide coaching, information, and referral services to patients managing various chronic health conditions on-site at the health center, via telehealth, and/or in a home setting

• Identify and address gaps in care and/or services to provide relevant community and/or health care resources

• Work closely with the care management team and build efficient and effective relationships among care team members, including outreach to external organizations that support a positive outcome for patients

• Complete annual care management competencies and any other relevant competencies/trainings as needed.

• Recognize the patient as a contributing member of the clinical team