Care Guide

Care Guide

Requirements

• Certificate, Associate degree, or Bachelor’s degree in a healthcare field. Education must be obtained from an accredited institution. Degree will be verified.
• 36 credit hours of college coursework
• two years of experience navigating a complex organizational system (e.g., college/university studies, military service, healthcare organization, federal programs)
• two years of military service experience
• two years of work experience in healthcare
• Strong interpersonal, written, and verbal communication skills
• Experience working in a collaborative, team-oriented environment
• Strong computer skills and willingness to continuously improve them: navigating reporting platforms, managing data spreadsheets, word processing, e-mail and the internet
• Experience managing competing demands in a high-paced environment

Responsibilities

• Understands, practices, and promotes the philosophy and guiding principles of Care Management.
• Develops relationships and collaborates with case/care management staff across the continuum to promote process integration, seamless transitions from one case/care management program to another, continuity of care, and avoid duplicative care management services/process.
• Monitoring pending and prioritized referrals for the CM team.
• Pre-screens new cases and assigns an appropriate primary planner based on patient needs.
• Collaborates with team member to improve clinical quality measures.
• Responsible for patient follow-up calls to re-enforce education, self-management, and other necessary care planning actions.
• Collaborates, educates, communicates, and networks with healthcare providers across the continuum to ensure the patient’s care planning needs are met.
• Advocates on behalf of patient, communicating and collaborating with healthcare providers, payers, physicians, and community-based services to assist in establishing an appropriate and integrated care for each patient.
• Promotes and supports mental health integration by collaborating with mental health/behavioral health providers.
• Responsible for designated transition management duties to ensure an effective transition of care from one healthcare setting to another.
• Actively participates in system and regional process improvement initiatives to improve transitions of care.
• Promptly and accurately performs assigned duties to facilitate day-to-day operations and communication in relationship to care management services.
• Promptly escalates concerns to appropriate chain of command.
• Supports interdisciplinary care conferences, using collaborative practice models that promote interdisciplinary care planning and teamwork.
• Completes timely and accurate documentation in the medical record using knowledge of documentation standards for the department to facilitate communication with team members.
• Organizes and prioritizes daily work by assessing new and current patient needs in area(s) of responsibility to ensure that productivity standards are met.

Preferred Qualifications

• Two years of college healthcare related coursework.
• Bilingual in English and Spanish.
• Understanding of medical and pharmacological terminology.