The Case Manager is responsible for managing chronic illness patients with regards to the Patient Centered Medical Home (PCMH) to promote effective education, self-management support, and timely healthcare delivery to achieve optimal quality outcomes. Is proactive in assisting the Center to achieve the goals of the PCMH. Supports and follows through with the vision, mission, goals and objectives of the Family Healthcare of Hagerstown.
Ensuring quality of care by coordinating treatment provided to patients diagnosed with chronic illnesses.
Collaborates with provider and practice staff in identifying appropriate patients including diabetics, patients with depression and hypertension for case management utilizing PCMH guidelines. Ensures patient’s labs are up-to-date and appropriate education is provided.
Conducts initial and periodic assessments for case managed population. Prioritizes patients according to complexity, need, and required follow-up. Documents the assessments in the patient’s chart in the EHR/EDR.
Maintains databases on case managed population. Maintains accurate and timely documentation to include care plan, education and resources provided, within 24 hours of patient contact. Appropriately schedules patients and provides accurate coding for face to face visits.
Identifies and effectively utilizes community resources to meet the needs of patients/families. Works with the Center’s Community Outreach Worker for those who have barriers to access to care.
Formulates and implements a case management plan that addresses the patient’s identified need by assessing barriers, resources, and PCMH goals. The plan is documented in the patient’s chart in the EHR/EDR.
Promotes patient self-management by reviewing PCMH Care Plans with patients/families to improve compliance and involvement.
Performs all duties and responsibilities in accordance with Maryland’s Board of Nursing requirements and in accordance with basic principles and guidelines of professional nursing.
Is proactive in contacting patients who fail to keep scheduled case management appointments or as directed by providers.
Provides additional education, resources, and training for the PCMH ‘High Risk’ Patients to improve their high-risk behavior.
Manages distribution of medication vouchers, reconciliation of monthly invoices and maintains a data base of medication dispensed to include monetary amounts and number of patients served.
Coverage of the triage phone to include evaluating the priority of the need for an appointment and the appropriate time frame.
Coordination of patient care for all FHH practices. Examples may include but are not limited to the following, Dental OR cases & children seen on the mobile unit: Assessment of children at high risk not receiving treatment & follow-up with Child Protective Services; mental health patients follow up with community resources and medication monitoring, obtaining documentation of hospital/ER admissions or specialist reports, facilitating presented plans of care/orders from home health to confirm medication lists and current PCP and collaboration with provider/support staff to encourage compliance with treatment.
Assists with grant management to include providing statistics and data related to grant criteria.
Maintenance of AEDs within the Center.
Demonstrates a professional image through on-going self evaluations, seeking professional growth while promoting effective relationships with all Center personnel and guests.
Demonstrates regard for, dignity toward, and respect for all patients, families, guests, and representatives of other organizations to ensure a professional, courteous, and responsive environment.
Performs job responsibilities with attention to safety concerns relating to staff, equipment, and the facility.
Maintains respect for employees and volunteers, and their individual commitment and contributions in support of the CHC’s mission to provide consistent quality services.
Other duties as assigned.
Current RN license to practice in the State of Maryland.
Proficient typing skills to enter data into the EHR efficiently.
Proficient computer skills to include launching applications, managing ‘Windows’ and Templates in the EHR, and using a Tablet PC.
Prior Case Manager experience preferred. Family Practice preferred.
Minimum physical effort required. Intermittent sitting with freedom of movement. Occasional walking, bending and lifting.
Frequent periods of concentration with attention to details with frequent opportunity for diversification of tasks. Must have excellent communication skills as well as be able to speak, write, and understand the English language. Must be able to work independently.
ENVIRONMENTAL & WORKING CONDITIONS:
Work performed in modern well-equipped environment. Interfaces with fellow employees on a daily basis. Uses office equipment daily, multi-line telephone, fax machine, copier, shredder, and computer.