Overall Purpose

This position is responsible for ensuring that assigned patient population(s) receive continuous, comprehensive and coordinated care throughout the continuum. Through case finding, data and other tools, high risk patients will be identified and guided to enhance the achievement of the Quadruple Aim: improved outcomes, improved experience of care for patients and providers and lower healthcare costs.

The Care Manager will utilize the nursing process of assessment, planning, implementation and evaluation as well as clinical judgment. Interventions with patients and / or stakeholders may be face to face or telephonic. The Care Manager may be responsible for activities overlapping with utilization review and quality management programs.

Work Location & Schedule

This role offers a hybrid work arrangement. Candidates will follow our hybrid schedule, working in office three days per week (Monday, Wednesday and Friday).

Essential Functions:

• Promote the mission, vision and values of P3 Health Partners
• Responsible for comprehensive patient assessments through medical records, clinician and patient interviews, telephonic and / or face to face
• Develops, implements, updates, and evaluates patient individualized care plans
• Collaborates with the interdisciplinary team regarding individualized care plans and patient’s progress
• Identifies patient care needs and barriers to care
• Develops and implements plans to mitigate barriers to self-management or care
• Prepares documentation according to P3 health partners workflows and policy
• Coordinates care for patient population
• Works with patients, families and caregivers to promote self- management and meet care plan goals
• Builds relationships with PCPs, internal and external customers
• Addresses quality gaps in care
• Other patient care projects as assigned

Knowledge, Skills, and Abilities:

• Strong clinical judgment and problem -solving skills required
• Excellent communication skills with patients, providers, internal and external customers required
• Must have excellent computer skills
• Must have excellent organizational skills and ability to work independently, with minimal supervision

Experience:

• Minimum two years of clinical experience, care management, and/or experience with a managed care/HMO organization, required.
• Discharge planning experience preferred
• Understanding of Utilization management preferred
• Understanding of HEDIS Measures preferred

Pay range: $65,000-80,000 depending on experience