The Clinical Care Manager is responsible for promoting organizational values of patient and visitor satisfaction by demonstrating courtesy and respect for families, visitors and other employees. Collaborates with practices and actively provides clinical support to "high-risk" patient populations for multiple practices - in all age groups ranging from young adulthood through geriatrics. Demonstrates competence in the assessment, treatment and care of patients serviced. Will include face to face (travel required), telephone or telehealth encounters as appropriate to patient needs.
Designs and implements care management support activities for high risk patients with chronic diseases and high medical service utilization.
Collaborates with physician and practice staff in identifying appropriate patients for care management utilizing established criteria. Collaborates with the patient and provider to establish and implement a care management plan using evidence-based guidelines. Develops patient objectives and measures progress according to standards of care.
Triages patient telephone calls and provides consultation regarding ongoing symptom management resulting from treatment and disease, analysis of intervention regarding diagnostic work-up, assessing and managing acute emergencies, managing family concerns as needed, liaison activities with affiliated physicians, nurses, pharmacists and emergency rooms.
Initiates appropriate evaluation and management of emergency situations.
Coordinates patient’s management/treatment plan throughout the institution.
Instructs patient/family regarding medications and treatments. Educates patients regarding health and illness prevention. Recommends community resources to meet patient and family needs. Develops patient education programs.
Creates, uses, and maintains patient-specific care management tracking system that identifies/ reports on patients who will benefit from care management services, the subsequent patient progress, and associated interventions.
Supports QA and maintenance efforts for patient registries and quality reporting. Works with the Clinical Analyst to summarize and analyze data from registries
Promotes patient self-management and empowers patient and families to achieve optimal health outcomes. Assists patient to identify and/ or develop and utilize their support systems.
Evaluates the effectiveness of care management plan in meeting established care goals and revises the plan as needed to reflect changing needs, issues and goals.
Prepares and maintains appropriate documentation as required.
Collaborates with all members of the health care team to resolve patient health, social or behavioral health needs.
Provides monitoring and continuity of care between physician visits. Maintains and reviews patient records, charts and other pertinent information.
Associate's Degree NLN- approved school of nursing
Bachelor's Degree Nursing and 1+ years prior nursing experience in internal/family medicine and care management experience
Licenses, Registrations, and Certifications
Req Pref Licenses/Registrations/Certifications Active PA or NJ RN license based on position location. Dual (NJ & PA)
RN licensure required within 3 months of hire RN
We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.