Chronic Care Manager, Population Health/Value Based Care

Chronic Care Manager, Population Health/Value-Based Care

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The CRC Care Manager will function as a member of the Care Coordination Team and will facilitate coordination, communication, and collaboration with patients, providers, transfer center, ancillary services, and leadership to achieve goals and maximize patient outcomes through an innovative whole-person Chronic Care strategy by working with CRC, Hospitals, MSOs, and IPAs. Best practice focus will be placed on the provision of care coordination which includes the recognition of the necessary patient advocacy through engagement, outreach, and providing linkage to resources. CRC Care Manager will educate and connect Emergency Department and/or in-patient to a home or alternative facility as appropriate, facilitate post-discharge appointments, and medication or other at-home needs through social service providers.

The CRC Care Manager serves as an advocate for the patient, educating the member and family of their health needs, coaches and offers alternatives to in-patient admission for providers and the patient. The Care Manager must understand a wide range of complex medical, social, and/or behavioral health needs/actions by identifying barriers, level of care needed, services, and resources required. Then by accessing company and community-based resources, as well as utilizing other support systems, the Care Manager assists the Emergency Department (ED) clinical teams in determining the best level of care and support services needed to provide care at the appropriate level. The Care Manager facilities the research and arranges placement of patients who can not be discharged home due to social drivers and other concerns. By avoiding unnecessary admissions, the Care Manager plays a significant role in reducing potential hospital-based infections and declination in the patient's condition due to depression and other untoward events which may happen in the in-patient setting. By seeking and placing the patient in the most appropriate level of care, they enhance the overall well-being of the hospital by engaging them in the management of their care. This support will lead to an improvement in life circumstances pointing them to better health outcomes as well as, financial efficiency from the clinical and social investment of dual-risk hospital-IPA relationships.

The CRC Care Manager is a clinical professionally trained and experienced team member skilled at engaging with patients and families during and after their ED/hospital visit, working with the facilities' physicians, hospitalists, and clinical care team to enhance patient-centered care and outcomes following ED discharge.

In partnership with the CRC Medical Director, IPA Medical Director, and Hospitalists, the CRC ED/IP/OP Care Manager ensures the aforementioned programs are a collaborative process of identification, assessment, planning, intervention, coordination, and evaluations and as appropriate; integrates the participation of all those involved in the care of the member, including the primary care physician, medical and surgical specialists, nurses, behavioral and mental health specialists, physical, occupational, and speech therapists, social workers, allied health professionals, and community-based providers.

Job Responsibilities/Duties

• Independently plans, develops, assesses, and evaluates care and discharge plans provided to dual-risk members. Recommends alternative levels of care and ensures compliance with federal, state, and local requirements.
• Responsible for the review of patient triage upon ED/IP presentation, utilizing the appropriate tests and diagnostics in the correct setting, and identifying alternative sources of treatment beyond the ED/IP setting and social barriers to discharge. Proactively researches, identifies, and recommends a course of care/treatment to ED/Hospitalist physician, approves alternatives to hospitalization, makes the discharge arrangements, and effectively communicates with patient's physicians, third-party facilities, and family to achieve the highest level of care most efficiently. Utilizes currently approved criteria along with advanced clinical experience to make authorization decisions.
• Responsible for the interdisciplinary approach to providing continuity of care, including Utilization Management, Transfer Coordination, and Identification of patient conditions that warrant different levels of Aid Category and initiates notification and application for the patient to be reassigned to the most appropriate Aid Category which results in additional resources and revenue to support patient needs. Proactively identifies members with serious and complex conditions, screens and identifies appropriate patients for the appropriate CRC Chronic Care Complex, Disease Management, and Complex Care Services Performance Improvement care coordination programs.
• Responsible for effective Discharge Planning including providing all authorizations/approvals as needed for outside services. Provides patients and their families with education and support services to assist with their discharge and help them cope with psychological and physical barriers and challenges which relate to their acute and chronic illness as well as reduced readmissions.
• Responsible for the review, analysis, and identification of utilization patterns and trends, problems, or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, budgetary planning, or routine utilization monitoring activities.

Minimum Education: Graduate Degree in Nursing.

Minimum Experience: Five (5) to Ten (10) years of experience in an Acute Care role, which includes ICU, PACU, and Medical Surgical services. At least three (3) years in a care management level role in a hospital and/or medical group is required. Must have care management leadership experience preferably in complex patient management, Chronic Care management, and/or population health roles. Prior experience and demonstrated successful performance improvement of the health of patients under managed care agreements. Must have excellent verbal and written communication skills in English with fast-paced problem-solving skills and the confidence to quickly implement resolutions. Required to have skills to independently utilize software such as Outlook, Word, Visio, PowerPoint, and Excel, as well as electronic health record documentation and research expertise, preferably with Allscripts EHR. Must have fluency in standard care management and utilization screening tools such as LANEs, Medex, MCG, and InterQual. Must know DRG, value-based, risk-based (capitation), and per diem payment methodologies as well as Medi-Cal, LTSS, Regional Care, and other government assistance programs. The position is in Southern California, Orange County, based Remote. Must be able to drive to our hospitals for patient, family, and physician meetings. Candidate must have a quiet, private work area, and high-speed broadband internet connectivity which will sustain a Microsoft Teams, Allscripts, Power BI, and Microsoft environment.

Req. Certification/Licensure: Unencumbered California Registered Nurse (RN). Certified Case Manager (Commission for Case Manager Certification) (CCMC). AHA Basic Life Support.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals, benefit-eligible positions will receive:

• Company 401K
• Medical, dental, and vision insurance
• Paid time off
• Life insurance

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation, or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www.eeoc.gov/