Care Manager, Population Health, Santa Barbara, CA
Care Manager, Population Health
GENERAL STATEMENT OF DUTIES: The Care Manager, Population Health is a Registered Nurse who will work with members of Sansum Clinic’s Value-Based Care programs including Medicare Shared Savings Program ACO, Medicare Advantage plans, and Patient Centered Medical Home. The aim of these programs is to improve quality of care, increase access to care, and provide coordination of care while reducing the total cost of care. The Care Manager achieves this by using data and analytics to track patients within specific populations and performing appropriate interventions and care coordination to ensure Preventive Health Care Gap closure, optimal management of chronic conditions, and seemless transitions of care. The Care Manager serves as a key member of the patient Care Team by facilitating communication amongst Care Team members through use of care management tools within the EHR and by navigating patients through the care continuum.
SUPERVISION RECEIVED: Clinical Informatics Manager
SUPERVISION EXERCISED: None
PHYSICAL REQUIREMENTS: Ability to stand, walk, stoop, kneel, crouch and/or crawl. Ability to sit or stand for long periods of time. Ability to reach, grasp, use fine finger movement and feel fine sensation to discern temperature, texture, size and shape. Good visual acuity, hand eye coordination, accurate color vision. Ability to speak and hear. Ability to use personal protective equipment when required.
ENVIRONMENTAL CONDITIONS: Patient care environment with potential exposure to unpleasant odors, communicable diseases, medicinal preparations, potential exposure to toxic and hazardous drugs, electrical hazards and other conditions common to a clinic environment. Climate controlled, indoor environment. Occasional exposure to outdoor climate. Work may be stressful at times.
MACHINES/EQUIPMENT USED: Clinical and office equipment.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES: (This list may not include all of the responsibilities assigned.)
- Provide care management services for members of specific populations to close gaps in care for past due/needed tests & procedures (i.e. past due or out of range HbA1C, mammograms, colonoscopies, etc.). This will include multiple different forms of direct patient outreach, coordination with the Care Team, Patient Access Team, and more.
- Facilitate transitions of care from specialist and inpatient setting to primary care.
- Coordinate patient care across teams and departments to ensure optimal management of chronic conditions.
- Appropriately document findings and interventions within the Electronic Health Record to ensure an accurate reflection of the patient's care.
- Utilize computer systems to track and prioritize a large population of patients efficiently including Excel as well as a variety of reporting tools withing the EHR.
- Collects, completes, and submits statistical data for key metrics in a timely manner.
- Employ a broad knowledge base of clinical terminology, outcomes, workflow, and exercise judgment to balance the needs between general goals and clinically critical requirements.
- Partner with other members of the Population Health team to ensure optimal coordination of care and patient experience.
- Report on care management activities and outcomes both verbally and in written presentation formats.
- Completes special projects as assigned.
- Works as a team player supporting a variety of staff.
- Displays a caring and responsive attitude and conducts all activities respecting patient, family and employee rights and expectations.
- Demonstrates sound cost containment techniques.
- Adheres to established safety requirements and procedures to ensure a safe working environment.
- Maintains and evaluates own clinical expertise and practice. Recognizes legal and policy limits of individual practice.
- Maintains certification and license requirements and submits required evidence of certification/licensure as needed.
- Adheres to all policies and procedures.
- Completes annual performance and competency evaluation process with management and participates in goal setting, performance improvement and educational training as needed.
- Participates in department quality improvement, clinic safety, infection control and hazardous materials programs/activities.
- Participates in professional development activities and maintains professional affiliations.
- Attends required meetings and participates in committees as requested.
- Adheres to HIPAA regulations.
- Exercises discretion and maintains high level of confidentiality.
- Performs related work as required.
KNOWLEDGE, ABILITIES, AND SKILLS: Knowledge of nursing scope of practice, clinical terminology, clinical workflows, diagnosis coding and terminology, clinical quality measures, and care management concepts. Knowledge of common safety hazards and precautions to establish a safe work environment. Ability to communicate well with patients, families, co-workers, physicians, other members of the healthcare team, etc. Ability to adapt to varied, age-specific and/or specialized groups. Ability to understand use, function, interpret, document, and keep records. Ability to learn and utilize case tracking, documentation and reporting tools within the EHR. Ability to interpret, adapt and apply guidelines and procedures. Ability to react calmly and effectively in emergency situations. Ability to read, write and communicate effectively in English. Ability to organize and prioritize work. Ability to follow oral and written instructions. Ability to reason and make sound judgments. Skill in identifying problems and recommending solutions. Skill in establishing and maintaining effective working relationships with co-workers, management, patients, medical staff, and the public. Skill in accepting constructive criticism and giving suggestions in a professional manner.
EDUCATION, EXPERIENCE AND LICENSURE:
- Must have a valid license in the State of California as a Registered Nurse. BSN preferred.
- At least 5 years of nursing experience in an outpatient care setting required.
- Proven proficiency with Excel and Powerpoint required.
WE CARE STATEMENT: As a Sansum Clinic employee, the Care Manager, Population Health commits to uphold and contribute to the WE CARE culture, serving, communicating and caring wholeheartedly for our patients and colleagues during every encounter, every time.
As a Sansum Clinic employee, the Care Manager, Population Health commits to:
- Welcome warmly and sincerely
- Engage wholeheartedly
- Communicate the plan
- Ask questions to deepen understanding
- Reassure best interests are in mind
- Exit with appreciation and thanks