Description
- Job Details
- The Integrated Case Manager for Population Health is an interdependent member of the patient-centered care team.
- Responsible for the collaborative practice of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual's health care needs.
- Provides services to patients from ambulatory, inpatient or health plan settings.
- Conducts a comprehensive assessment of patient and family/caregiver's needs to gauge the potential impact on recovery.
- Develops personalized patient-centered care plans aimed at optimizing the patient's care experience.
- Engages patients and their families as part of the care team through ongoing communication, health education, and service facilitation.
- Utilizes judgment, critical thinking, and motivational interviewing techniques to assist patients in overcoming barriers.
- Provides counseling and interventions related to treatment decisions and end of life issues including Advanced Care Planning.
- Advocates for appropriate delivery of services within the patient's health plan benefit structure.
- Evaluates the patient's response to the care/treatment plan and makes necessary modifications.
- Job Requirements
- Experience in discharge planning, home health care, rehabilitative medicine, community health or managed care preferred.
- Knowledge of preventive service guidelines, clinical practice guidelines, behavior change theory, Medicare and Medicaid regulations, and case management principles.
- Knowledge of medical ethics and legal implications related to case management.
- Understanding of social determinants of health and their impact on a patient's wellbeing.
- Strong organizational, planning and implementation skills with the ability to handle multiple complex patient needs simultaneously.
- Strong sense of compassion with the ability to successfully advocate for patients and their families.
- Additional Details
- Excellent verbal communication and written documentation skills.
- Excellent customer service and interpersonal skills including the ability to interact with all levels of the organization.
- Strong computer skills and knowledge.
- Well versed in facilitating community resources to meet the needs of diverse populations.
- Must meet or exceed core customer service responsibilities, standards and behaviors.
- Demonstrates flexibility in an environment of constant change.
- Work in a clinical environment with potential exposure to communicable disease.
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