Join an independent physician practice in Morganton, North Carolina! Solid Rock Family Medicine is searching for an experienced LPN – Care Manager to join our staff. 

Position Summary

The Chronic 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

Position Duties

The primary purpose of the Care Manager is to address the programmatic and preventive needs of assigned patient population by assessing, planning implementing, coordinating, monitoring and evaluating the options and services required, and using communication and available resources to promote quality, cost-effective 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 an RMA preferred
• Experience in managed care is highly preferred
• Must possess a valid driver’s license
• Personal vehicle is required for travel between work sites

KNOWLEDGE, SKILLS and ABILITIES (KSAs)

• Excellent communication skills both oral and written
• Considerable knowledge of case management principles
• Ability to work with minimal direct supervision
• Able to adapt to changing healthcare environment and program needs to best meet the needs of clients and agency
• Knowledge of government, private organizations and community resources
• Skill in establishing rapport with a client and applying techniques of assessing psychosocial, behavioral, and psychological aspects of a client’s problem
• Knowledge of and compliance with federal and state regulations applicable to the position 
• Analytical skills necessary as independent decisions and problem solving are required 
• Strong organizational and computer skills required including various office software and internet
• Ability to prioritize using sound clinical judgment

WORKING CONDITIONS

• The job environment is primarily a combination of office, work at home, patient homes and medical facility environments
• Exposure to general office and household conditions as well as communicable diseases could occur
• Routinely there may be some minor physical inconveniences or discomfort in the work setting, including sitting for moderate periods of time
• There is occasional lifting of 20-30 pounds necessary to complete a task
• Evening and weekend work may be required at times