MHN Care Manager - Chicago, United States - Christian Community Health Center

Description

Non-Exempt or Exempt (Depending on Licensing)
Direct Supervisor/
Reports To
Position
Summary

The Care Manager is an Illinois licensed individual (in any specialty) who provides patient care through a diverse role as a clinician, educator, care coordinator and advocate.

The Care Manager works in a collaborative relationship with internal and external members to support patients, families and the MHN.

The individual is an expert in chronic disease management, prevention, health maintenance, and clinical evaluation of medical and psychosocial needs.

The individual who holds this position exemplifies the CCHC mission, vision and values and acts in accordance with CCHC policies and procedures, including complying with all CCHC Customer Service Standards.

Responsibilities Include but are not limited to:

Works with complex, high cost, high utilization patients, and conducts comprehensive health risk assessments (CRA), medication reconciliations and health integrations.

Utilizes Medical Home Network (MHN) portal in order to identify patients in need of outreach efforts from a clinical and psychosocial perspective.

This will be based on MHN patient stratification and the patient's Medical Home's Care-Management certification level as well as defined Disease management guidelines.

Works with care management team, patient's Medical Home, all other providers of the patients care and patient and their caregiver to develop individualized care plan/goals.

Works to improve identified outcomes as defined by MHN ACO.
Facilitates communication with patients and care team, coordinate referrals, and promote optimal allocation of available resources.
Adheres to evidence-based treatment guidelines in facilitating care for chronic care/ disease management.
Contributes to documentation of individualized care for identified patients, focusing on specific treatment goals. Assess progress toward goals based on clinical judgment, review of patients' self-monitoring tools and trends in clinical data.
Assesses and monitors adherence to outreach and problem-solve intrinsic barriers to effective patient self-management of chronic conditions (i.e. education level, language barriers, etc.).Identifies extrinsic barriers to adherence (i.e. transportation, financial concerns or pharmacy coverage) and work with patient, care team and other available resources to alleviate barriers.

Provides educational materials and resources to patient and family that are in a format which is specific to the patient/family learning abilities and language preference.

Refers patients/families to self-management support programs as needed.

Assists with the timely follow-up and Management of care for MHN patients discharged from hospital settings requiring complex care management.

Communicates with internal and external care providers (specialty consultants, home health agencies) to ensure safe and effective care management.
Analyzes clinical data to track patient outcomes to determine if case management has improved patient status.
Triages patient phone calls for acute patient issues and counsels accordingly.

Participates in medical home quality improvement initiatives; activities may include data collection, chart review, interdisciplinary collaboration, analysis of patient data and inter-professional staff meetings.

Performs related duties as required.
Minimal Qualifications/
Experience/
Skills

Current Licensure in the State of Illinois (in any field).
Exceptional communication skills, both written and oral, ability to positively influence others with respect.
Strong critical thinking and analytical skills required. Must have a strong sense of compassion and strong interpersonal skills.
Ability to function independently, to organize and prioritize effectively, and be self-motivated.
Christian Community Health Center is an EOE.

As a non-profit organization, we expect our employees to work and perform within our mission, in order to have a harmonious work environment.

Our mission is, "To provide high quality health care and related services to the community regardless of the ability to pay.

Provide service in a manner which demonstrates in word and deed, the love of Jesus Christ."

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