Integrated Care Manager

JOB SUMMARY:

As an integral member Population Health Management Initiative, the Integrated Care Manager is responsible for establishing, implementing, monitoring, and evaluating high-quality, cost-effective care for a designated group of patients in the ambulatory based setting.

Consistent with a team-based care model, the Integrated Care Manager (ICM) may be embedded in select NWPHO affiliated primary care practice(s) and will collaborate with the primary care physicians and other members of the patient's care team to plan and implement optimal and efficient care plans and design approaches to care for a defined population of patients managing their care across the continuum.

This position requires a broad knowledge of clinical care, available health services across the continuum of care, insurance benefit design and reimbursement methods, care integration systems and management and experience in acute care or community case management.

The ICM will demonstrate prudent nursing judgment, effective problem-solving skills, critical thinking, excellent organizational and interpersonal skills, creativity, flexibility, and the ability to multi-task.

The ICM will update and educate him/herself in matters relating to care coordination, applicable Federal and State regulations, risk management, community resources and other pertinent topics.

ESSENTIAL FUNCTIONS:

Major duties and responsibilities:

Care Management: Communication/Coordination

* Routinely consults with the patient's PCP, mental health, and specialist physicians as well as other members of the PCMH team to identify and validate high priority patients.

* Conducts outreach and completes assessments for patients identified in benefiting from care coordination services. Outreach may be telephonic, electronic or in person contact.

* Develops a patient centered plan of care and provides patient/family health education and coaching for an identified panel of patients

* Incorporates self-care and promotes shared decision making in all aspects of patient care.

* Serves as a key resource to an assigned group of patients in one or more primary care practices, helping to proactively address their questions, concerns, and care needs by guiding and facilitating access to providers and services.

* As appropriate, directly provides ongoing community-based care management services and/or refers patients to other care management programs such as provider-based disease management programs or insurance-based specialty case management programs.

* Establishes a consistent schedule of communication and reporting with involved providers and the patient with intended goal of reviewing patient status and progress toward goals.

* Collaborates with and seeks feedback from primary care physician, interdisciplinary team and/or the community care management leadership team regarding challenging patient situations.

* Communicates with other health care clinicians throughout the continuum about patient's care needs, utilization plan and applicable follow up plans.

* Utilizes electronic medical record systems to document, monitor, and evaluate patient interventions and care plans.

* Acts as a clinical resource for NWPHO quality initiatives.

* Participates in regular meetings with iCMP management and NWPHO leadership to review performance, patient caseloads, programmatic goals and engage in special projects as identified.

Utilization

* Incorporates knowledge of case management standards, payer rules and coverage, and utilization management principles to implement high-quality, cost-effective care.

* Provides information and education as necessary to other members of the care team regarding insurance benefit design and coverage, health care options and available community resources.

* Influences appropriate utilization of health care resources by coordinating patient care across the continuum, encouraging involvement in disease and case management programs, and conducting follow-up care prior to and post interaction with the broader health care system including acute care admissions, emergency department visits, specialist visits, and sub-acute care settings.

* Using medical management criteria and/or other Partners approved diagnostic screening criteria, collaborates with hospital and/or post-acute staff to understand the appropriateness of hospital and/or sub-acute admissions, length of stay and readmissions.

* Authorization and coordination of services which may include determining appropriate level of care, management of patient's health benefits, authorization for approved services in compliance with federal and state standards and in compliance with health plan guidelines as appropriate as well as referrals to community agencies.

* Notifies the primary care physician and care team, iCMP manager and/ or NWPHO leadership regarding over and under utilization of services including patient specific factors which may influence utilization patterns.

* Conducts case reviews at practice, program and /or care coordination meetings.

* Provides information and education as necessary to other members of the care team regarding insurance benefit design and coverage, health care options and available community resources

.

Post- Acute Management

* Works with the interdisciplinary team to assess the needs of patients in the home, office practice, emergency department or hospitalized in observation status, who may be appropriate for a direct admission to a skilled nursing facility.

* Educates patients and families about Accountable Care Organizations, Medicare Advantage products and commercial insurance plan benefits including but not limited to skilled nursing and certified home health eligibility and limitations.

* Collaborates with patient's medical providers and SNF partners to expedite and arrange transfer to a post-acute setting (SNF).

* May collaborate with Transitions Care Managers and post-acute partners to assure appropriate patient length of stay.

* Ensures that the discharge plan of care, regardless of location, is adequate and alerts iCMP leadership, the primary care provider as well as facility leadership if adjustment of the plan is warranted. Collects, analyzes, trends and reports SNF Waiver and other sub-acute utilization activity.

ORGANIZATIONAL RESPONSIBILITIES:

* Demonstrates a positive attitude in dealing with patients, co-workers, and other health care providers and in addressing problems and/or crisis situations.

* Establishes professional, collegial relationships with physicians, health care providers and staff in the physician's office, community agencies, hospitals, and other health care facilities.

* Demonstrates initiative and creativity to continuously improve services, work processes, and engage in activities that promote standards of high quality and prudent utilization.

* Is aware of and follows applicable NWPHO policies and procedures for general safety, fire safety, infection control and attendance.

* Assumes accountability for professional growth and development including a working knowledge of trends in ambulatory care management including topics related to Population Health Management, PCMH, and ACO, risk sharing agreements and regulatory changes to the health care environment.

* Identifies quality of care issues and reports the concerns to the appropriate party.

* Flexibility with tasks and assignments, including coverage of office practices as iCMP needs indicate. Examples include assisting colleagues at other practices and providing coverage during vacations/unexpected illness/holiday time.

Performs other duties as assigned

Predominately office based and but may work in a variety of settings including hospital. Flexibility required to meet with patients/family and providers in the hospital, in the community and in the primary care practice. Travel between locations is required. Hours and work schedule will be flexible to meet the needs of patients, families, hospital, and staff, but will generally follow a Monday-Friday eight-hour work schedule.

* RN graduate of an accredited school of nursing and currently licensed to practice in Massachusetts.

* Minimum of 5 years experience in hospital, health plan or community case management or utilization management role.

* Preferred qualifications include:

o BSN, BS, or BA

o Certification in case management (CCM), (ACM) or other applicable professional certification

o Previous experience working in a post acute setting such as LTAC, acute rehabilitation, skilled nursing facility, or homecare.

o Previous experience working in an ambulatory setting such as a health center or physician's practice.

o Managed care or health care reimbursement experience with a working knowledge of nationally accepted utilization review criteria (InterQual, Milliman).

* Evidence of continued education and professional development.

• Critical thinking and problem-solving skills. Demonstrates autonomy in decision making
• Uses prudent judgment based upon objective information, clinical experience, and nursing process.
• Strong organizational skills with an ability to manage routine work, triage and reset
• priorities as needed.
• Interpersonal skills and ability to work effectively with physicians and their staff in a physician practice setting to develop rapport, build trust, and promote Population Health initiatives. Excellent oral, written, and telephonic skills and abilities.
• Competency in working with multiple health care computer platforms.
• Ability to work effectively in a complex fast paced medical environment and multiple practice locations