Concerto Healthcare Care Manager in Kalamazoo, Michigan

br/bConcerto Healthcare/bbr/br/Concerto Health and its subsidiaries are an Equal Opportunity Employer. We do not and will not discriminate in employment or personnel practices on the basis of race, color, religion, national origin, ancestry, alienage or citizenship status, age, disability, sex, sexual orientation or any other characteristic protected by applicable federal, state or local /bHealthcarebr/bPosted Date: /bNovember 08, 2018br/bSchedule: /bFull-Timebr/bLocation: /bKalamazoo, MI, United Statesbr/br/br/JOB SUMMARY brThe care manager acts as an advocate to coordinate the continuum of care for our patients. This role requires a high level of interaction with our patients to: br1. Perform effective telephonic outreach to complete necessary health and social assessments br2. Engage them in the development of an integrated, patient-centered care plan that takes into account needs across the continuum of care (health, social, psycho-social) br3. Support the patient in achieving their own goals as stated in their care plan as well as monitor adherence to treatment plans or other disease/chronic condition management programs brThe care manager works with a multi-disciplinary care team to develop interventions and changes to the care plan in response to patient's needs and promotes positive health outcomes. brbrESSENTIAL DUTIES AND RESPONSIBILITIES br• Perform comprehensive, team-based, and person-centered patient engagement br• Conduct patient onboarding, including performing health risk assessments in accordance with (health plan) model of care requirements br• Creates and develops patient care plans that addresses all problems, goals and interventions identified using appropriate mediums (e.g. historical claims data, outreach logs, completed assessments, etc.) in Concerto's care coordination record system br• Identify high risk patients (based on risk stratification criteria) who require a high frequency of care coordination and contact br• Identifies caregiver training needs and tracks impact of needs and or training br• Completes transition of care process in accordance with health plan guidelines; includes outreach during hospitalization, and conducting assessments upon discharge to ensure successful transition to another setting br• Identify the appropriate utilization of resources across the continuum of care br• Participate in quality improvement and evaluation processes br• Work closely with the Pharmacy Benefit Manager and community pharmacies to help coordinate medication accessibility and medication refills br• Perform and document reassessments, revisions to care plans, and coordinate interdisciplinary care team meetings in accordance with the (health plan) model of care requirements br• Coordinate activities with Treating Providers, Utilization Management Team, Social Services Team and Disease Management Team as needed br• Complete all mandatory regulatory and other trainings required (including but not limited to: compliance training, first tier downstream and related (FWA) entity training, model of care training, etc.) br• Knowledge of Healthcare Effectiveness Data Information Set (HEDIS) and engagement with members on care gap closure br• Regular and consistent attendance br• Other duties as assigned brbrQUALIFICATIONS br• Current RN License in good standing in the state of practice required Preferred Certified Care Manager (CCM) certification or commitment to completion within 1 year of hire br• Minimum of 3 years' experience in a clinical setting br• Demonstrates the ability to triage and apply c