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Job Summary:

As a member of the Population Health Management (PHM) Team, the Outpatient Case Manager works with members, providers and caregivers to provide intensive, comprehensive case management and increase efficient utilization of services for patient with complex needs; identifies chronic, complex and or catastrophic cases through the case management process and or referrals and initiates intensive case management according to program guidelines. This role will utilize multiple disciplines as CM to focus on various different patient populations. The goal of the PHM OP Case Manager is to effectively manage patients on an outpatient basis and during episodes of acute hospitalizations (in conjunction with their inpatient counterparts) to assure the appropriate level-of-care is provided, optimize safe transition to home or the next level of care, prevent inpatient re-admissions and ensure that the patients' medical, environmental and psychosocial needs are met over the continuum of care. The Case Manager acts as an advocate for members and their families linking them to other appropriate disciplines on the care team to facilitate patient/family education for better self-management, navigation of the health care system, and to identify community resources as necessary. The PHM OP Case Manager: - Will be embedded and connect with patients face to face or on the phone - Telephonic only Both types will coordinate with other members of the PHM team or multidisciplinary care team to adequately coordinate and manage patient needs Telephonic Case Management Focus: Will have a role that primarily the same as the outpatient PHM OP case manager, but will follow patient telephonically only and will support more multiple physician practices or patient populations based on patient volumes.

Core Responsibilities and Essential Functions:

Assessment - Reviews all patient referrals to determine criteria met for case management. - Performs comprehensive assessment to identify patient/family needs. - Identify all high risk areas, including medical, environmental and psychosocial areas - Reviews all options/resources available to meet client/family needs and to promote optimum health and the most cost effective manner. Planning - Collaborates with the patient/family, physician and Multidisciplinary team in the formation and modification of a comprehensive and individualized plan of care which addresses the needs and goals of identified high-risk patients with complex chronic conditions. - Integrates evidence-based clinical guidelines, preventive health guidelines, protocols, and other identified risk information in the development of plans of care that are patient-centric, promoting quality and efficiency in the delivery of healthcare for high risk population. - Develops and/or utilizes processes that monitor patients across the health continuum with a focus on effective and safe transitions from hospital to home, nursing home or rehab facility with goal of optimizing resources and reduction of avoidable acute care readmissions. Implementation - Matches the patient/family needs to available and appropriate resources to carry out the plan of care. Utilizes telephonic and face-to-face communication as appropriate to engage with and to meet needs of patients. - Prioritizes and collaborates with patients/families/healthcare providers regularly to optimize patient engagement and clinical outcomes in the most efficient manner. - Coordinate patient care services necessary to meet patient needs. Makes appropriate referral to other team members to assist with resource needs. - A strong emphasis is placed on Wellness, Disease Management and patient education to ensure compliance with the plan of care and prevention of complications with various ailments and chronic conditions. - Identify care gaps and works with team to close the gaps - They will coordinate member visits with primary care providers and specialists as needed. Monitoring/Evaluation - Monitors care through data collection and analysis. Evaluates processes utilizing a systematic approach to determine the effectiveness of the case management plan in terms of reaching desired outcomes and goals to improve the quality, access and cost of care. - Manages performance feedback metrics to further refine the care model to maximize clinical, quality, and fiscal outcomes for the targeted population. - Participates in team meetings to evaluate current processes, provide and receive feedback, review specific cases with goal of problem-solving for improved patient adherence to plan of care, clinical outcomes and patient/provider satisfaction.

Required Minimum Education:

Graduate of accredited school of nursing with a current Georgia RN license. Required and Bachelor's Degree in Nursing Preferred

Required Minimum License(s) and Certification(s):

Reg Nurse (Single State) 1.00 Required RN - Multi-state Compact 1.00 Required Basic Life Support 2.00 Required BLS - Instructor 2.00 Required BLS - Provisional 2.00 Required

Additional Licenses and Certifications:

Required Minimum Experience:

Minimum 5 years in clinical experience Required and Case Manager certification (CCM) Preferred and Computer experience with Microsoft office suite and electronic health records Preferred and Experience in data collection and analysis and basic research techniques desired. Preferred

Required Minimum Skills:

Knowledge of complex case management role and processes. Demonstrates customer focused interpersonal skills to effectively interact with practitioners, multidisciplinary health care team, community agencies, patients and families with diverse backgrounds, values, and religious/cultural ideals. Outgoing and autonomous, flexible personality that can engage the geriatric population over the phone and support the development of PHM CM role.. Demonstrates leadership qualities including excellent organizational and time management skills, verbal and written communication skills, problem-solving, decision-making, priority setting, and work delegation. Ability to utilize risk-stratification screening criteria, review clinical data in identifying patient/client health care needs.

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