Cape Fear Family Medical Care is searching for an RN / LPN / RMA to join their team as a Clinical Care Manager. Our independent physician practice is located in Fayetteville, North Carolina.  

The Clinical Care Manager provides ongoing care coordination to individuals with both physical and behavioral health conditions. Patients with two chronic conditions qualify for more intensive management to ensure that the patients understand the treatment plan and are managing their conditions as expected. Another population who are targets for Chronic Care Management are patients who frequently use the emergency room and hospital for their ongoing care. This transitional care includes:

• Medication Reconciliation
• Provides disease management and education.
• Discuss ED/hospitalization encounters with patient to improve outcomes.

JOB DUTIES

• Care Managers work in concert 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
• Assess patients for conditions and concerns that are able to be addressed through community care management
• 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

QUALIFICATIONS

• Degree in Nursing or RMA
• 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