Full Time 40 hours Grade 044 Primary Care Administration Responsibilities General Purpose: The Clinical Care Manager manages clinical aspects of patient centered medical home, working with the interdisciplinary medical team in the provision of patient care. May participate in supervision of other clinical staff members. Specific Responsibilities: Under general direction of the Site Medical Director, the Clinical Care Managerâ™s central role integrates and coordinates access and utilization management, proactive patient management, care facilitation and treatment planning functions. The Clinical Care Manager will demonstrate this commitment through implementation of the following: Coordinates medical care of patients identified as high risk by health risk assessment/appraisal or by physician clinical determination.Assumes coordination role at the point of service and through targeted outreach and follow-up. Identifies patient groups with chronic diseases. Assists in developing and implementing population-based strategies to close gaps in medical care.Identifies resources for patient self-management skills. Identifies resources for patient self-management skills. Assists in developing and implementing care plans for medically complex patients. Identifies barriers to a successful care management path. Coordinates use of clinical and ancillary resources within and outside of the health system to achieve treatment goals specified in the patient care plan. Participates in program development by: Assisting with planning short-range and long-range program goals for chronic disease management. Keeping abreast of organizational developments and practices that may impact operations by participating in continuing education courses, professional organizations and seminars, reading current literature and maintaining professional contacts in the community. Assisting with the development of current evidence based protocols, policies, work flow/flow sheets, guidelines, etc. related to the provision of care within the medical home model. Participating in committees as assigned. Interacts effectively with physicians, the home care team, patients, and their caregivers. Accountable for patient triage. Adheres to infection control/safety guidelines. Adheres to HIPAA, JCAHO, and OSHA regulations and policies. Requirements: Associate of Applied Science in Nursing and a minimum of five years of professional nursing experience. Outpatient primary care and/or pediatric (if applicable) experience in community health, care management, and/or disease management is preferred or; an equivalent combination of education and experience. Registered in New York State. Current CPR certification required.
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