PURPOSE
With oversight and direction from the Population Health Program Manager, assists in maintaining all aspects of providing care management and care coordination for patients in the primary care setting, as well as effectively assisting in the management of the Care Management team to provide work flow efficiencies, compliance, teamwork, and smooth transitions of care.
PRIMARY RESPONSIBILITIES AND DUTIES
- Provides support and meets regularly with the Care Management Department Manager concerning management issues and activities and the status of projects. Assists in identifying and evaluation of the methods for improving care management workflow and makes recommendations for improvement.
- Provides support to the Care Management Department Manager with the day to day activities of the program. Acts as a liaison between employees and management when necessary.
- Upon the request of the Care Management Department Manager, identifies and provides training support to the Care Management team. This may include developing and preparing materials as well as tabulating course evaluation forms.
- In conjunction with the Care Management Department Manager, evaluates unit policies, procedures, and processes, and recommends/implements changes to ensure assigned unit is functioning efficiently.
- Attends meetings and participates on committees as directed.
- Prepares agenda, takes notes, and prepares minutes for Care Management Department meetings lead by or as assigned by the Care Management Department Manager.
- Provides coverage for administrative or direct care duties during regular business hours.
- Maintains proper attendance, stays within attendance policy guidelines. Demonstrates flexibility in scheduling.
- Develops, maintains, and monitors the progress of comprehensive individualized care plans for patients in need of care management, including following up with physician/patient/family follow up, communicating with hospitals, and reconciling medications.
- Manages patient care through coordination of specialists, community resources, members of the health care team, and patients/families.
- Provides patients and families with any education and resources necessary to manage their illnesses or diseases outside of the clinic.
- Maintains necessary documentation and electronic health record reports, including all care management activities, ACH patient files, and any external registries.
- Identifies process issues and helps develop and maintain efficient care management processes in collaboration with others as appropriate.
- Develops clinical and preventative guidelines and protocols for developing care plans.
- Maintains confidentiality of protected health information and safeguards all patient related information at all times.
- Special projects as assigned.
INDIVIDUAL CHARACTERISTICS
General Development
- Displays significant organizational skills, in order to manage and direct the activities of one or more functional areas of the organization.
- Provides leadership and motivation to others.
- Develops priorities for effective performance of duties, including re-prioritization in response to changes in circumstances.
- Devises effective solutions to situations encountered based on the general goals and objectives of the function.
- Draws conclusions using inference and logic, which may be different than the conclusions that could be drawn by others.
Professional Knowledge
- Possesses specific advanced knowledge skills, including written and verbal communications skills, computational, computer and technical skills, and mathematical knowledge frequently acquired through completion of a Bachelor’s Degree program with a recognized major.
- Performance of the duties and responsibilities of the job requires the equivalent of extensive formal training in nursing, including an understanding of the application of the theory and practices of the profession to the operations of the organization, usually in the form of a major in nursing as part of an applicable extended training program.
- Requires an understanding of the trade/profession at a level that allows the employee to select methods for others to use (from those already in existence in the profession).
Licenses and Certifications
- Possesses a current Michigan state licensure to practice nursing.
- Possesses a current Basic Cardiac Life Support (BCLS) CPR certification.
- Possesses a current State of Michigan driver’s license and valid automobile insurance.
Technical Skills & Abilities
- Prepares more complex documents in Microsoft Word, including creating tables, charts, graphs and other elements.
- Uses Microsoft Excel to analyze data, including the use of formulas, functions, lookup tables and other standard spreadsheet elements.
- Develops sophisticated presentations in Microsoft PowerPoint, including the use of embedded objects, transitions and other elements.
Communications Skills
- Effectively communicates their opinions and extrapolations of information they collect and synthesize/analyze.
- Resolves conflicts that may arise because of disagreements between employees, between employees and customers/clients, or with the public, other legal entities or governmental authorities.
- Requires the effective communication of written information (including electronic correspondence).
- Requires the compilation and analysis of information prepared in effective written form, including correspondence, reports, articles or other documentation.
- Requires preparation and execution of presentations to large groups.
- Requires the effective communication of information during informal and formal verbal presentations.
- Requires employees to effectively convey technical information to non-technical audiences.
- Convinces others to take actions, or to behave in a specific way desired by the employee.
- Employees must determine appropriate methods of communicating information through the use of tables, graphs, charts and other visual forms
PHYSICAL CONDITIONS & WORKING ENVIRONMENT
- Job duties are typically performed in a typical school and clinic environment.
- Job duties require ability to travel by personal vehicle and public transportation.
- OSHA Category I Job Classification for occupational exposure to blood and other possibly infectious materials.
