Care Manager

Job Requirements

Position Summary

The Care Manager plays a pivotal role on Spartanburg Regionals population health team. This position coordinates and oversees patient care across diverse populations, including but not limited to pediatric, adult, and geriatric patients. The role is to assess patient’s needs, develop personalized care plans, and coordinate services to support the patients/care givers physical, mental and social wellbeing.

The goal of the care management program is to improve patient health outcomes and satisfaction while reducing overall healthcare costs by coordinating care, providing patient centered support and providing preventive care for moderate -high risk patients, those particularly with chronic conditions. Key objectives include enhanced patient engagement, better disease management, reduced hospitalizations and emergency room visits, and addressing social and behavioral factors that impact health.

Minimum Requirements

Education

- Graduate of an accredited school of nursing, Bachelor’s Degree (other than nursing) with an ADN or an accredited school of Social Work (MSW)

Experience

- 3-5 years of healthcare experience in outpatient setting, population health, social services, home health, or other health care setting OR 1-3 years Care Management experience (Care Coordination, Transitions of Care, or Outpatient Case Management)

License/Registration/Certifications

· Active SC Registered Nurse license if RN

· Active SC Social Worker license if Social Worker

· Valid US driver’s license with driving record with active and up to date SC car insurance

Preferred Requirements

Preferred Education

- Bachelor of Nursing (BSN)
- Licensed Independent Social Worker for Clinical Practice (LISW)

Preferred Experience

- 6-8 years of experience in outpatient setting, population health, social services, home health, or other health care setting.

· Motivational Interviewing

· Epic Experience

· Health coaching

· Chronic Condition Management

· Home Visit Experience

· MS Office

· Motivational Interviewing

Preferred License/Registration/Certifications

· Accredited Case Manager (ACM)

Core Job Responsibilities

· As a Care Manager, you will be responsible for proactively engaging and enrolling moderate to high-risk patients, with multiple chronic diseases, low socio-economic status to support the members’ whole-person health.

· Must be confident calling patients/caregivers to explain the care management program and its benefits to enroll in various programs.

· Once patients are engaged, you will assess, evaluate, and coordinate the patients physical, behavioral, and support needs, to identify and help resolve any barriers that hinder effective care.

· This includes, but is not limited to, the assessment and development/updating of member Individualized Care Plans, managing medications, and providing the self-management tools beyond the counseling and guidance typically provided during visits with their providers.

· As a core component of the Care Management team, the Care Manager facilitates communication between different providers in the advocacy of members, often being in contact with multiple doctors, nurses, and specialists to best coordinate the directives of each provider into a seamless plan for the member.

· Care manager must be willing to work with a variety of patient populations, including but not limited to, pediatric, adult, and geriatric.

· Provide or facilitate resources internally or in the community for patients/families and make referrals and provide follow-up as appropriate (e.g., SDOH, social services such as housing assistance, vocational rehabilitation, substance use treatment, food, transportation, etc.).

· Coordinate transitions of care from one provider to another or from one care setting to another.

· Provide telephonic and face to face outreach to engage members and assess their readiness to change by using motivational interviewing techniques to help patients/care givers identify and overcome barriers that often include behavioral risk factors, poor health literacy, sedentary lifestyle, and poor disease management.

· Facilitation and/or procuring timely access to appointments and services required by the patient.

· Must be flexible and adapt to changes in the work environment, manage competing demands, change the approach/method to best fit the situation and be able to cope with delay or unexpected events.

· Perform facility visits, not limited to; inpatient, home, office/clinic, SNF/Rehab, within a designated time frame. Requires 30-40% field work.

· Communicates clear, complete and accurate documentation in a health record to ensure that all those involved in a client's care have access to necessary information to plan and evaluate their interventions.

· Ensure the proper handling of patient records to ensure compliance with patient health information applicable to the preservation, accuracy, and completeness of communication and/or retention of patient information, meeting all HIPAA regulations and the HITECH Act provisions as required by law

· Must meet productivity and quality metrics set for by direct supervisor and leadership.

· All other duties as assigned