Care Manager
Lakeland Care
RN Case/Care Manager
CenterWell Senior Primary Care
full-time
Posted on:
Origin: • 🇺🇸 United States • Arizona
Visit company websiteSalary
💰 $71,100 - $97,800 per year
Job Level
Mid-LevelSenior
About the role
- Working within an interdisciplinary care integration team (CIT), proactively engaging patients and implementing targeted interventions to address whole person health and increased access to care
- Provide guidance and oversight of care coordination efforts to other members of the team, and manage clinical escalations
- Conduct Transitions of Care Management for a subset of the patient population, including hospital, obs, and post-acute care follow ups
- Provide triage guidance and supportive consultation to other team members, handling escalated complex cases
- Develop care plans leveraging 5Ms Geriatric best practice framework
- Identify existing barriers to engagement with necessary resources and supports related to Social Determinants of Health
- Provide education around maintenance of chronic health conditions, behavioral care and social support options
- Serve as liaison between the patient and direct care providers, assisting in navigating both internal and external systems
- Initiate care planning and subsequent action steps for high-risk members, coordinating with interdisciplinary team
- Refer patient to necessary services and support (transportation, food insecurity, benefits navigation including Medicaid, HCBS, medication cost reduction, scheduling follow ups, alleviating social isolation)
- Lead Interdisciplinary CIT Team Meetings when indicated and participate in CIT interdisciplinary review of and coordination around complex patients
- Assess patient’s family and caregiver system, and conduct family meetings when needed
- Document patient encounters in medical record system in a timely manner and maintain patient confidentiality in accordance with HIPAA
- Participate in creation and facilitation of team training content
- Regular onsite engagement with the care team to assigned clinics to see patients in person and collaborate with care team members
Requirements
- Registered Nurse (RN license)
- Minimum of 4 years of experience working in human services and navigating community-based resources
- Advanced clinical acumen
- Ability to multi-task in a fast-paced work environment
- Flexibility to fluidly transition and adjust in an evolving role
- Excellent organizational skills
- Advanced oral and written communication skills
- Strong interpersonal and relationship building skills
- Compassion and desire to advocate for patient needs
- Critical thinking and problem-solving capabilities
- Driver's License, Reliable Transportation, Insurance (valid state driver's license, carry insurance in accordance with state minimum limits or $25,000/$25,000/10,000 whichever is higher and a reliable vehicle)
- Bilingual in English and Spanish or Creole preferred (ability to speak, read and write in both languages without limitations nor assistance)
