Job Description

Job Description

Certification Details

• BLS

Job Details

• Integrated Case Manager for Population Health is a member of the patient-centered care team responsible for assessment, planning, facilitation, care coordination, evaluation, and advocacy to meet comprehensive health care needs.
• Addresses needs of patients with critical events or diagnoses requiring complex management and extensive resource use to optimize health outcomes.
• Provides services to patients from ambulatory, inpatient, or health plan settings.
• Conducts comprehensive assessments of patient and family/caregiver biomedical, psychological, social, and functional needs.
• Develops personalized patient-centered care plans to optimize patient care experience.
• Engages patients and families through advocacy, communication, health education, and resource facilitation.
• Uses professional judgment, critical thinking, motivational interviewing, and self-management techniques to assist patients.
• Provides counseling and interventions related to treatment decisions and end of life issues including Advanced Care Planning.
• Coordinates patient transitions between care settings to ensure seamless and safe care.
• Advocates for appropriate delivery of services within patient health plan benefit structures.
• Collaborates with care team members to co-manage patients with complex medical and social needs.
• Evaluates patient response to care plans and modifies as necessary.
• Participates in process improvement activities to reduce risk, including data collection and analysis.
• Facilitates interventions in cases involving abuse and neglect (child, domestic, elder, institutional, sexual assault).
• Supports department goals contributing to organizational success.

Job Requirements

• Excellent verbal communication and written documentation skills.
• Excellent customer service and interpersonal skills with ability to interact with all organizational levels.
• Strong problem-solving, analytical, and decision-making skills.
• Strong computer skills and knowledge.
• Experience in discharge planning, home health care, rehabilitative medicine, community health, or managed care preferred.
• Knowledge of preventive service guidelines, clinical practice guidelines, behavior change theory, Medicare and Medicaid regulations, and case management principles.
• Knowledge of medical ethics and legal implications related to case management.
• Understanding of social determinants of health and their impact on patient wellbeing.
• Well versed in facilitating community resources to meet diverse population needs.
• Strong organizational, planning, and implementation skills to handle multiple complex patient needs.
• Strong sense of compassion and ability to advocate for patients and families.

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