Overview

The CHT Care Manager is a grant funded staff position responsible for providing care management across the continuum of care for patients identified as high-risk, high-complexity at Gifford.

The CHT Care Manager will work collaboratively with other members of the care team, using motivational interviewing techniques, and behavior modification techniques to set goals and develop action/care plans to promote wellness and help individuals realize their part in maintaining their health. This position sometimes functions as the lead care coordinator of a patient’s care team and works with providers, office staff and extended CHT resources to identify and provide care coordination for patients with or at risk for chronic conditions. The CHT Care Manager will work closely with patient and provider to establish a plan of care to improve the patient’s physical and mental health, quality of life, and self-management skills.

The Vermont Blueprint for Health is a state-led program that aims to integrate a system of health care for patients; improve the health of the overall population; and improve control over health care costs by promoting health maintenance, prevention, care coordination, and management.

This position will maintain absolute confidentiality of all referred patients’ records, medical treatment and diagnoses, and comply with all policies and procedures of Gifford Health Center.

Benefits

• Competitive wages
• Onsite parking and childcare
• An excellent retirement plan
• Health plans including dental, vision, short- and long-term disability
• Discounted gym membership
• Employee discounts at local retailers

Duties and Responsibilities:

Identify high risk patient populations

• Contacts patients who are referred and utilizes assessment tools to determine health needs and readiness for change.
• Utilizes data and patient panel reports to proactively identify patients needing care management for selected chronic diseases and health maintenance.
• Analyzes patient care trends and actively seeks out and collaborates with the Medicine Division to improve overall quality of care.
• Works collaboratively with Emergency Department (ED) to develop action plans to help reduce potentially avoidable ED utilization.
• Works collaboratively with hospital departments to ensure contact and follow-up for patients with or at risk of chronic conditions after discharge from inpatient care.
• Works with the practice staff to ensure outreach to patients identified through panel management.

Support patient self-management of chronic conditions

• Manages care coordination of high risk and/or complex patients associated with the Gifford Health Service Area.
• Organizes and facilitates care team meetings and works collaboratively with community resources.
• Collaborates with the patient/family, Medical Homes and other members of the Community Health Team to develop a comprehensive plan of care based on a systematic assessment of the physiological, psychosocial and socioeconomic needs of the patient and family, and to address identified barriers to self-management.
• Builds and maintains a therapeutic relationship to support clinical and self-management plan of care.
• Acts as a Medical Home liaison for patients/families and external agencies and individuals. Assists with completion of plans of care, and other similar documents as needed and with the approval of the medical provider.
• Responsible for assisting patients with health literacy, providing telephonic and in-person coaching, counseling, consultation and information and referral services to patients with a goal of self-management of their chronic health condition(s).
• Serves as a resource for self-management support.

Support patient self-management pf chronic conditions

• Complies with all facility, state and federal regulations associated with healthcare, including HIPAA, certification and licensure, etc.
• Maintains knowledge of complex patients’ plans of care.
• Maintain knowledge of internal and external resources.
• Maintains current knowledge of local, state and national healthcare initiatives.
• Reinforces the role and importance of collaboration among health care professionals within an integrated system.
• Acts as Gifford CHT liaison to community agencies, consumer groups and programs.
• Demonstrates critical thinking for problem solving and prioritization.

Assist in Program Development

• Participates in hospital-wide process improvement, NCQA Medical Home survey preparation and compliance, and clinical outcomes improvement as assigned.
• Recommends revisions, changes, and strategies as needed to improve programs.
• Participates effectively as a team member, attending practice staff/team meetings and working closely with all members of the health care team to improve quality of care, while supporting Patient Centered Medical Home goals and objectives.
• Consistently strives, working in conjunction with a multidisciplinary team, to assure that the patient is receiving the right service at the right time at the right cost, following organizational quality guidelines/measures (ACO/NCQA/MU, etc.) or Medicare/Medicaid and all contracted commercial insurance plans.

Quantify and track activities

• Participates in quality improvement studies and activities on an ongoing basis. Participates in professional development and community organizations as appropriate to maintain current knowledge of the care coordination process.
• Documents patient activities and coaching/counseling outcomes in electronic health record.
• Documents activities on electronic tracking forms and in applicable care management software.
• Participates in refinement of tracking tools.

Requirements

• RN currently licensed in the state of Vermont is required.
• Minimum 2 years of experience with case management/care management in a healthcare setting, including experience with assessment, motivational interviewing techniques, healthy living strategies, therapeutic lifestyle change and counseling preferred.
• Experience in a primary care clinical/medical office setting working with patients of all ages preferred.
• Knowledge of available resources within the Randolph Health Service Area and in the surrounding community; program implementation and quality improvement strategies; state-wide health care reform initiatives; and ACO/NCQA/UDS clinical performance measures preferred.
• Electronic health record experience preferred.
• Demonstrates computer competency including all Microsoft Office applications.

EOE