- Works with the Primary Care Provider (PCP) and the community to coordinate a full continuum of health care services considering the patient's unique social and cultural dynamics
- Act as a liaison between the PCP, local Health Department (HD), Department of Social Services (DSS), local hospitals, and other community agencies by identifying, arranging, and coordinating physical and/or behavioral health care services in concert with the PCP
- Collaborate with network providers in assuring appropriate client management
- Build and maintain relationships with community service providers through collaboration, networking and educating at community functions
- Assist patients in addressing concerns as needed through referral for assessment, counseling and communication with healthcare team
- Maintain appropriate client documentation in the EHR
- Develop and implement individualized care management plans for identified clients
- Provide direct follow-up and outreach services via face to face encounter (home visit, provider office visit, or community encounter), phone or mail
- Educate clients and families on the importance of medical care management and the proper method to access care within the medical home environment
- Educate recipients about disease states to include medication adherence, prevention and risk factor reduction
- Ensure follow-up with hospital discharge instructions for high risk, high acuity, high cost recipients; ensure continuity of care
- Act as a liaison to providers to ensure the use of Evidence Based Practices
- Assist providers with coordination of services for high risk, high acuity, high cost recipients by implementing Evidence Based Practices
- Coordinate, develop and provide health care education programs and trainings
- Advocate for patients to receive services that will improve their health condition
- Assess patients' plans of care for any duplicate or unnecessary services to control costs to payor
- Audit charts and compile data to support the disease centered initiatives
- Responsible for maintaining patient and family confidentiality in accordance with HIPAA
- Other job duties as required
- Degree in RMA or Nursing (RN or LPN)
- Experience in direct patient care / managed care is highly preferred
- Must possess a valid driver's license
- Personal vehicle is required for travel between work sites
- HEDIS Quality Measures experience
- Excellent communication and customer service skills required Proficiency in Word, Excel, and PowerPoint required.
- Ability to work independently, while collaborating with other team members
- Ability to self-motivate, prioritize, and be willing to invest in a change process to improve efficiencies
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Clinical Care Manager
4 weeks ago
EMrecruits Fayetteville, United StatesJob Description · Job DescriptionCape Fear Family Medical Care is searching for an RN / LPN / RMA to join their team as a Clinical Care Manager. We're an independent physician practice located in Fayetteville, North Carolina. · The Clinical Care Manager provides ongoing care coor ...
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Clinical Care Manager
3 weeks ago
EMrecruits Fayetteville, United StatesJob Description · Job Description · Cape Fear Family Medical Care · is searching for an · RN / LPN / RMA · to join their team as a · Clinical Care Manager. · We're an independent physician practice located in Fayetteville, North Carolina. · The · Clinical Care Manager · ...
RN, LPN or RMA - Fayetteville, United States - EMrecruits
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Description
Job Description
Job DescriptionCape Fear Family Medical Care is searching for a Transition of CareRMA / LPN / RN to join their team. We're an independent physician practice located in Fayetteville, North Carolina.
The Transition of CareRMA / LPN / RN tracks patients who are discharged from the hospital and offers ongoing care coordination. This transitional care includes medication reconciliation, disease management and education and discusses ED / hospitalization encounters with patients to improve outcomes.
JOB DUTIES
QUALIFICATIONS