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About the Role
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 education, coordination, coaching, transfer of self-management skills, and addressing barriers. Guidance will be provided to patients and families to improve population health, enhance care quality, and decrease costs. Integrated patient-centered care plans will be developed with the patient to improve outcomes. Care management activities will occur in health centers, via telehealth, and occasionally at the patient’s home, hospital, or other community setting.
Responsibilities
- Provide outreach, information, guidance, and education to patients, families, primary care providers, and care team members regarding healthcare utilization, chronic disease self-management, care transitions, barrier assessment and elimination, wellness, and preventative care.
- Develop individualized, goal-oriented, patient-centered care plans that promote positive outcomes and address physical health, mental health, and socio-economic barriers.
- Maintain ongoing responsibility for assigned caseload by prioritizing referrals and activities based on intensity, needs, and required follow-up.
- Provide coaching, information, and referral services to patients managing chronic health conditions in health centers, via telehealth, or in home settings.
- Identify and address gaps in care or services by providing relevant community and healthcare resources.
- Collaborate with the care management team and build effective relationships with care team members and external organizations.
- Complete annual care management competencies and other required trainings.
- Recognize the patient as a contributing member of the clinical team.
Requirements
- Bachelor’s Degree in a health or human service field, or equivalent combination of experience and education.
- Applied professional experience in case (care) management and/or social work.
- Current BLS certification.
- Experience working in healthcare, behavioral/mental health, or substance/alcohol abuse fields is preferred.
- Valid driver license and ability to travel throughout the Network.
- Strong verbal and written communication skills.
- Proficient computer skills including Microsoft applications, electronic medical records, and related databases.
- Well-organized with the ability to effectively manage multiple cases and projects.
- Self-directed, detail-oriented, and motivated.
- Ability to work independently and collaborate effectively with colleagues, supervisors, partners, and healthcare professionals.
Skills
- Communication
- Organization
- Time Management
- Collaboration
- Independent Work
- Detail-Oriented
- Motivation
- Computer Proficiency
- Electronic Medical Records
Location
- Chester-Horicon Health Center
- Bolton Health Center
- Indian Lake Health Center
- North Creek Health Center
Work Type
- Full-time
- Hybrid
Experience Level
- Professional Experience
Education Level
- Bachelor's Degree
Salary/Compensations
- $24.97/hour