Care Manager - Certified Medical Assistant

Summary of job duties

Under the direction of Value Based Care Leadership, the Care Manager 1 provides and facilitates communication of health information and performs clerical and clinical documentation and other support services for patients in Care Management programs. The incumbent is responsible for triaging, coordination of care, documentation, communication, and tracking patient calls, cases and records. They engage patients and their families and/or representatives for disease management and education sessions to promote positive health and behavioral modifications, assists in the development of care plans, and encourages and facilitates engagement with the Primary Care Provider, specialists, and other community-based healthcare providers. The Care Manager 1 provides information for basic social services, application assistance, and care planning for patients, as needed. He/she provides transition of care services to patients being discharged from post-acute settings, such as hospitals and skilled nursing facilities. He/she is responsible for ensuring billing and documentation is complete for chronic care management eligible patients.

Essential job functions

• A general knowledge of primary care clinics, disease management and medical terminology is essential. Competency in prevention strategies and care planning for patients with comorbidities (chronic health conditions, behavioral health, and substance abuse). Experience in care coordination, health education, patient engagement and social services is required. Knowledge of hospitals, specialists, and ancillary health services throughout the assigned community is preferred.
• Provides Care Management services to a panel of traditional Medicare and Medicare Advantage patients who are assigned to his/her care.
• Works in collaboration with the patient's Primary Care Provider to create and modify patient care plans and associated patient goals and instructions.
• Assists patients with appointment scheduling, prescription filling and performs other duties directed by the PCP and Value Based Care leadership.
• Interacts with respect and in a professional manner with patients, staff and external customers.
• Provides assistance and supplemental support for Transitional Care Management Nurses and patients.
• Communicates with other health professionals, hospitals and community resources as the patient's advocate to support the continuum of care.
• Provides basic health education and disease management sessions to support positive behavioral change among Value Based Care patients.
• Reviews charts and requests outstanding information to ensure clinical documents from ER, urgent Care, hospitals skilled facilities and consult notes are on the patient's chart. Updates Care Team and medications lists.
• Assures that patient meets all quality measures, is taking medications and fulfilling orders for following up with specialists, completing labs and imaging as the provider directs for the patient's overall health and wellbeing.
• Documents the appropriate criteria for Chronic Care Management (CCM), Transitional Care Management (TCM), and behavioral health integration (BHI) for eligible patients and relays that information to the appropriate Care Management team member.
• Assesses and identifies specific patient social and preventative care needs. Facilitates resolutions (when possible) with community resources throughout an assigned geographic area.
• Participates in department rotating "on-call" schedule.
• Attends meetings for updates as directed.
• Follows HIPAA and OSHA Standards.
• Maintains HR compliance and procedures.
• Ensures patient satisfaction by providing excellent service, putting Patients First Always.

Qualifications

• Minimum requirements
• 2 to 3 years professional experience working in a primary care or post-acute setting OR 2 to 3 years of patient navigation, referral management or health education experience.
• Certified Medical Assistant, Health Coach, or Associate or Bachelor's Degree in a related area

Knowledge/Skills/Abilities

• Knowledge of legal and ethical standards for the delivery of primary care.
• Strong computer skills with knowledge of Microsoft Office products.
• Excellent verbal and written communication skills.
• Ability to work independently and in a multidisciplinary team.
• Ability to effectively utilize an electronic health record to document all patient encounters

Working environment

The position requires climbing, stooping, kneeling, crouching, reaching, standing, lifting, grasping, feeling, talking, hearing, repetitive motions, and finger use. Pushing and pulling are occasionally required. Use of a computer, keyboard, and telephone along with various office machines is an essential part of the job.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by the Care Manager 1. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. The Care Manager 1 may be required to perform duties outside of their normal responsibilities from time to time as needed or as directed by supervision.