Mssp Clinical Case Manager (Rn/Lpn)

Indiana Health Centers, Inc. (IHC) is a mission-driven organization that has been providing high-quality, affordable healthcare to underserved and uninsured populations since 1977. At IHC, a Federally Qualified Health Center, we specialize in integrated care which means having access to essential services to meet the needs of patients we serve in the community. With ten healthcare centers and eight Women, Infants, and Children nutrition program locations throughout Indiana, we offer primary medical, dental, and behavioral healthcare services to community-based patient populations that are diverse in age, educational background, and income level.

IHC is currently seeking to appoint a full-timeexperiencedRN/LPN for the position of MSSP Clinical Case Manager. The ideal candidate will have excellent communication and interpersonal skills, a strong clinical background, and experience working with MSSP. They should also be organized, detail-oriented, and able to work independently. If you meet these qualifications, we encourage you to apply for this exciting opportunity! This rewarding position comes with an exceptional benefits package including a $2000.00 bonus!

Overview:

The MSSP Clinical Case Manager contributes to IHC’s mission and goals of client satisfaction, quality of care, and productivity. The Case Manager facilitates communication between patients, their families, caregivers, providers, and other members of the healthcare team. Their focus is to offer individualized assistance to patients with complex disease states and multiple comorbidities, as well as their families and caregivers, to overcome healthcare system and community barriers and facilitate consistent and timely medical care across the continuum of care. The Case Manager is an integral part of the Patient-Centered Medical Home and Patient Care Team.

Operations functions:

• Perform social determinant of health (SDoH) assessments and link patients with appropriate resources
• Provide general care coordination orientation to patients and communicate the goals/objectives of the program
• Assist patients referred to/from providers, care managers, and other points of entry
• Guide patients through transitions of care from inpatient settings to home.
• Contact patients to facilitate continuity of care and escalate issues to appropriate team members
• Compile and distribute educational material per patient need
• Assist patients with adherence to existing self-management goals or development of new goals (in collaboration with practice clinical staff)
• Assist in identifying individual and/or community needs that encourage healthy lifestyles and environments (i.e., community resources, transportation assistance, exercise programs, etc.).
• Interact with the multidisciplinary team on behalf of the patient to resolve barriers. Communicate outcomes to patient/family/caregivers
• Maintain timely appropriate documentation on patient interactions in the care management system.
• Provide disease-specific and preventive care patient education
• Executes effective interventions to reduce inappropriate ER visits or length of hospital to improve care and reduce costs

Quality and administrative functions:

• Assist in the collection and assembly of quality improvement information to track and trend
• Participate in cross-functional team meetings aimed at improving patient outcomes or operational processes
• Regularly participate in care team huddles with care managers to identify priorities, tasks, and interventions
• Compile and distribute educational material based on patient need
• Perform follow-up activities with patients as needed after emergency department visits
• Assist with scheduling medical and specialty appointments. Provide reminder phone calls for appointments and/or follow-up calls post-appointment
• Retrieve discharge summaries and copies of medical records

Recruitment Package includes but is not limited to:

• $23.00-$29,00 hour (based on experience)
• $2000.00 retention bonus ($1000.00 paid after 90 days and $1000.00 paid after 1 year)
• 403(b)/403(b) matching
• Flexible spending account
• Health, life, dental, and vision insurance
• Health savings account
• Generous PTO
• Referral program
• Retirement plan
• Tuition reimbursement

• A validLPN or RN license in the state of Indiana required
• 2 years overall experience providing patient care in a community or hospital setting is required
• 1 year of case management experience or experience providing health education outreach
• Proficient in computer skills, including typing and use of Microsoft Word, Excel, Outlook, Access, eCW, SharePoint, Azara, etc.
• Care coordinator certification preferred
• Occasional travel is required to participate in offsite IHC meetings
• Must currently reside in Indiana