InnovaCare Management Services Company, LLC

Job Summary

The ACO Care Manager (CM) position is responsible for promoting patient quality of care and cost-effective outcomes by the process of assessment, planning, facilitation, care coordination, and the evaluation of comprehensive health needs. ACO CM is focused-on client centered services that link clients and other family members with health care, psychosocial and other home and community-based services to ensure timely, coordinated access to medically appropriate levels of health and support services and continuity of care. ACO CM is responsible for assessment, planning, coordination, advocacy, education, monitoring and accurate, timely documentation in all program areas. S/he demonstrates knowledge of growth and development and possesses the ability to assess, interact, communicate and care for age specific patient populations. ACO Care Manager works closely with patients, families, healthcare teams, and community resources to optimize continuity of care and improve patient outcomes.

Essential Job Functions

• Utilize clinical tools, data, and other information to complete patient needs.
• Create individualized and comprehensive needs assessment for care management and treatment plans.
• Document all treatment plans, tasks, and actions into EMR when applicable to meet turnaround times as documented in policy and procedures.
• Collaborate with Utilization Management (UM) staff in transition of care protocols to avoid readmissions and focus on meeting all CMS measures for transition of care (TOC) and Medication Reconciliation.
• Participate in quality improvement initiatives aimed at enhancing the effectiveness, efficiency, and safety of care transitions.
• Clearly validate prescribed treatments and treatment plans to patients to follow.
• Educate patients on available support services: social work programs, insurance company services and benefits along with other community resources to meet social determinates of health (SDOH) needs.
• Collaborate with patients, providers, and insurance companies for successful healthcare outcomes and to manage chronic and high-risk conditions.
• Document accurately complex medical information that outlines and demonstrates how to improve health results along with educating patients on Advanced Directives.
• Responsible for on-going monitoring and evaluation of patients.
• Follow care and quality management processes in compliance with regulatory guidelines and company procedures.
• Identify and address potential barriers to successful care transitions, such as medication errors, gaps in communication, and inadequate follow-up care.
• Maintain accurate and thorough documentation of care, assessments, interventions, and outcomes in accordance with regulatory requirements and organizational policies.
  
  

General Knowledge/Skills

• Must: Critical thinking and problem-solving skills.
• Preferred: Clinical knowledge of chronic conditions, management of high-risk patient populations and knowledge of available community resources.
• Strong knowledge of managed care concepts.
• Strong written and verbal skills with patients, physicians and other stakeholders including techniques in facilitating patient engagement in their healthcare.
• Demonstrate ability to timely assess and respond to patient and family needs.
• General knowledge of care (case) management practices, including familiarity with Medicare Advantage products, programs, and services.
• Experience in establishing professional and collaborative relationships with patients, providers, and insurance organizations.
• Basic computer skills, including working knowledge of the Microsoft Office suite.
• Not required, but preferred: Certification as a diabetes educator, nutritionist or social worker or other specialty.
  
  

Minimum Required Education, Experience & Skills

• Bachelor's degree in nursing, social work, or a related field
• Relevant active and unrestricted clinical licensure (MD, DO, ARNP, RN, etc.)
• Current Nursing License within the state in which you work or Compact License
• Minimum of 3 years of clinical experience in healthcare, with a focus on care coordination, case management, or transitional care.
• Continuing education in Care (Case) Management and all other applicable professional licensure.
• CPR/BLS certification.
• Strong knowledge of Medicare
• Strong knowledge of care management
• Strong knowledge of hospital-based care and transitional care management
• Strong leadership and communication skills and the ability to create working relationships with key stakeholders internally and externally.
• Ability to work collaboratively in a team-based environment.
• Proficiency in electronic health record systems and documentation practices.
• Excellent communication, interpersonal, and organizational skills.
• Ability to manage multiple priorities and deliver results in a fast-paced environment.
  
  

Physical & Mental Requirements: (check all that apply)

☐ Required immunizations and vaccinations.

☐ Ability to lift to 50 pounds.

☐ Ability to push or pull heavy objects using up to 100 pounds of force.

☐ Ability to stand or sit for extended periods of time.

☐ Ability to use fine motor skills to operate equipment and/or machinery.

☐ Ability to properly drive and operate a vehicle.

☐ Ability to receive and comprehend instructions verbally and/or in writing.

☐ Ability to use logical reasoning for simple and complex problem solving.

☐ Occasionally requires exposure to communicable diseases or bodily fluids.

☐ Occasional travel for clinic activities may be required (ex. InnovaCare meetings or training).

The information listed above is not comprehensive of all duties/responsibilities performed. This job description is not an employment agreement or contract. Management has the exclusive right to alter this job description at any time without notice.