GENERAL DESCRIPTION OF POSITION:
As a member of the clinical team, this position requires total support of the PCMH principles, policies, and procedures. Perform a variety of duties working collaboratively with all Clinical and Administrative staff.
Will supervise and direct the Care Management Team at all four Su Clinica clinical sites.
Implement and use care management and coordination tools, criteria, and protocols to assure and enhance the patient’s healthcare experience and outcomes. Ensures patient care is effectively delivered, managed, and coordinated with internal and external partners while encouraging patient involvement in decision-making. The care management director reviews the patient’s needs and guides care managers to meet patient needs by assisting in setting self-management goals.
Promotes effective and efficient utilization of clinical resources.
Provides direction to care managers to manage patients with chronic and acute conditions with the support, education, and assistance in the prevention and/or maintenance of their disease and/or health and wellness state and increase patient’s compliance with prescribed medical regimen utilizing current best practices.
Communicate with all community hospitals and care entities to ensure continuity of care.
Engage community resources to support patient’s needs and improve collaborative coordination of care.
Provides assistance and guidance to clinical staff as needed.
Collaborates with Value Based Care Team to assure ACOs, MCOs, Commercial insurances, traditional Medicare and Medicaid guidelines are met. Educates Clinicians and Clinical Staff on Annual Wellness Visits, Attestations, and any clinical deficiencies, new processes and products.
Ability to work with all Su Clinica clinical teams participate in Quality Review, Quality Improvement, Risk Management, Information Technology initiatives.
Participates in Chart Span directives and initiatives.
Serves as alternate CNO in CNO’s absence.
ESSENTIAL JOB FUNCTIONS: (With or without accommodations)
Ability to interview, mentor, evaluate, counsel, care management personnel.
Leads Su Clinica Care Management Team using care management evidence-based practices.
Communicates with Su Clinica Care Management Team in daily huddles.
As a member of the clinical team, this position requires total support of the PCMH principles, policies, and procedures.
Actively and accurately reviews and records in the medical record patient information collected to include healthcare updates on prescribed medical regimen. PCMH 2C, 3C
Works closely with special needs children/adults with special health needs to ensure continuity of care.
Actively participates in a multidisciplinary team huddles to coordinate care, scheduling and follow up along with the provider and front desk clerks to prepare for the patients scheduled, reviews opportunities for same day access, and alerts other disciplines for patients and families with and without special needs. PCMH 1A, 1B, 1G
Assists in developing in-service training and educational programs. Assures that clinical protocols and standing delegation orders are fulfilled for specified patient populations. Attends and completes required in-service training such as Compliatrics, Su Clinica training and other web-based courses and educational programs.
Conducts review of electronic and clinic records for appropriate utilization of service.(PCMH 2C, 3A).
Coordinates with other departments the role of patient care and the home planning process.
Engages patient and their care givers in understanding and setting self-management plans in a culturally and linguistically appropriate manner. ( PCMH 3C) Discuss any care questions from providers.
Engages patient and their care givers in understanding their care in a culturally and linguistically appropriate manner. ( PCMH 1F)
Facilitates telephone consultations, provider visits, or face to face visits with patients or care givers for care coordination, assess needs, and/or educate the patient. ( PCMH 1A)
Identifies barriers impacting the patient care and refers to appropriate support systems such as social workers, wellness counselors, etc. (PCMH 3D)
Identifies high risk patients for disease management and care coordination and works with patients and the primary care team to establish a plan of care to meet the patients’ needs. Example children/adults with special health needs.
Participate in quality improvement projects aimed at improving patient care outcomes for patients. ( PCMH 6)
Participates in providing training/education to SC employees or students when requested.
Performs duties within the scope of practice as delegated by provider through the use of approved standing orders and or protocols. (PCMH 2C)
Performs patient call backs in a timely manner and documents PCMH 1A
Initiates and engages patient in the transition of care with phone calls, scheduling appointments, and reconciliation of medications. Prepares tracking reports regarding hospital admissions and readmissions and reports findings to appropriate committee and primary care team. (PCMH 5C) Reviews activities that occur during the patient’s hospital stay, community agencies or at home to coordinate patient’s care. ( PCMH 5C)
Reviews discharge planning and coordinates discharge needs with facility, care givers and patients. Facilitates provider contact to coordinate patient’s needs. ( PCMH 5C)
Tracks TCMs to assure ACO, MCO criterias.
Serves as a patient’s clinical advocate.
Supports the PCP to implement the integrated plan to achieve desired outcomes and to satisfy contractual/regulatory requirements. Actively participates in performance improvement projects to improve patient care outcomes.
Teaches method of health promotion and disease prevention in accordance to individualized needs. Refers patient to appropriate resources \ referrals, social services, pharmacy, laboratory, etc. (PCMH 3C)
Verifies that patient’s and family members’ discharge and follow up questions have been addressed and appropriate educational materials provided and documented in the electronic medical records. ( PCMH 3C)
Works jointly with provider to maximize disease prevention and reinforce patient follow through with provider’s orders and instructions. ( PCMH 3C)
Works with patient and family members to enhance their understanding of the treatment plans on the disease process to include identification of early signs of decline in condition. (PCMH 4A)
Provides appropriate information to MCO’s such as annual wellness visits, attestations, and medication adherence.
Attends work on a regular and predictable schedule in accordance with clinic leave policy. Submits required documentation in a timely manner (credentialing requirements, license renewals, certifications, CNE attendance, etc.). Performs other duties assigned. Responsible for their own safety as well as the safety of others.
POSITION DIRECTLY SUPERVISES: All Su Clinica Care Mangers at all four sites.
KNOWLEDGE, SKILLS, AND ABILITIES: (use of equipment, job related knowledge, language, etc.)
Ability to complete basic/intermediate math computations and medical math conversions.
Ability to examine documents for accuracy and completeness and to maintain a flexible work schedule.
Ability to maintain an effective and professional working relationship with the public and co-workers.
Ability to maintain client, office confidentiality and abides by confidentiality expectations and HIPAA guidelines.
Ability to prepare records in accordance to detailed instructions.
Ability to read, write and speak in a clear, accurate and professional manner; includes active listening skills and understanding medical terminology and to recognize, evaluate, solve problems, correct errors and report to supervisor any issue.
Ability to resolve patient service issues and exercise independent judgment and to work in a fast-paced environment.
Ability to work with medical equipment to include but not limited to: electronic and manual vital signs measurement, oxygen and suction apparatus, peak flow.
Able to bend, stretch, stoop, stand, sit, and lift 20 lbs. and to show excellent interpersonal skills reflecting clarity, diplomacy and communicates accurately and effectively with all levels of staff and management.
Assist with the control of department budget by limiting mileage and overtime.
Able to apply critical thinking skills, multi-tasking, prioritization and attention to detail and make sound judgment at all levels throughout the patient’s continuum of care and make necessary referrals on behalf of Patient Provider or Caregiver as instructed by provider.
Knowledge of practice level procedures, techniques, and practice of patient care.
Knowledge of regulatory requirements, health plan contracts, governmental benefits and community resources.
Knowledge of SC policies and procedures.
Knowledge of the Chronic Care Model and Patient-Centered Medical Home Model (PCMH) and transition of Care management.
Able to navigate EMR and download and upload data into other websites and portals.
Able to review other data in EMR and research for specific diagnosis.
Communicates concerns to appropriate personnel using tact and diplomacy.
Demonstrates role in safety rules and emergency preparedness.
Does not abuse sick leave or other periods allowed away from the job.
Initiates prompt and accurate treatment, diagnostic screening and medications as ordered.
Interprets and translates for the provider when necessary.
Skilled in excellent customer service and makes customer service a top priority.
Skilled in use of computer and computer software (EMR, Microsoft Word, Excel, etc.) and telephone system.
Promotes teamwork, offering to help other personnel including students, float staff or agency personnel.
Responsible for their own safety as well as the safety of others.
Skilled in excellent customer service and makes customer service a top priority.
Ability to comply with enhanced infection control requirements of the clinic.
Submits required documentation in a timely manner (credentialing requirements, license renewals, certification, etc.)
Responds to Rapid Response activations at all clinic sites where present.
Nursing duties as assigned and needed to bring Su Clinica nursing to standard and above standards per governing bodies.
Special Instructions: Due to the nature of SC Services, it may be necessary for employees to work extended hours or other variations of the usual shift to ensure adequate care to patients and to maintain service to the community.
