Case Manager Pediatrics

Job Description

SUMMARY:

Under supervision of the Pediatrics Clinic Leadership, the Case Manager is responsible for managing a caseload taken from a population of individuals that meet clinical requirements for Chronic Care Management (CCM); working closely with clinical support staff, nursing leadership, physicians, and the population health department to achieve system goals of improving clinical outcomes for patients with chronic diseases; developing processes that support the CCM program, and ensuring all requirements have been met in order to bill and receive reimbursements that support the program for continued growth.  Additionally, case manager will be responsible for working medication adherence lists, to ensure patients are receiving prescribed medications, and that the organization is meeting quality requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

*Include the following. Other duties may be assigned.*

  • Manages a caseload of an assigned panel of chronic care patients, including patients with mental health issues. 
  • Collaborates with physicians, providers, and practice staff in identifying appropriate patients for care management.
  • Develops relationships with patients as an integral member of the team.
  • Provides follow-up management with patients to ensure compliance with their individual care plan.
  • Maintains availability to provide telephone advice per protocol and handles urgent and emergency calls during working hours.
  • Anticipates the needs of the patient population, seeing that necessary documentation and pre-visit planning is completed or requested before patient visit.
  • Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence.
  • Determines and coordinates appropriate referrals as needed.
  • Works with patients and patient’s care team to coordinate change readiness, needs assessment and to develop an individualized treatment care plan.
  • Collaborates with the patient, physician, and other care team members in assessing the patient’s progress toward individual health care goals.
  • Maintains accessible, consistent documentation of patient self-management measures, and reporting progress toward goals.
  • Assists patients in setting SMART goals for self-management, teaching them how to do self-management tasks, and reports abnormal findings to their physician team.
  • Assesses barriers when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments.
  • Oversees the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams.
  • Participates in regular team meetings and peer review activities.
  • Promotes collaborative teamwork and is able to work with peers in a team situation.
  • Collaborates with payer Case Managers for additional services when appropriate.
  • Maintains a list of medical supply and community resources available to patients and maintains collegial relationships with the entities used most frequently.
  • Makes recommendations for policies/procedures to ensure that preventive services are offered in a timely manner to all who qualify.
  • Provides follow-up in the transitions of care from various settings (hospital or skilled nursing facility discharges and emergency room visits).
  • Coordinates disease registry activities.

EDUCATION AND/OR EXPERIENCE:

The Case Manager must have knowledge of the Patient-Centered Medical Home model/mission as well as knowledge of insurance industry practices and requirements. He/she must have an understanding of chronic disease and preventive care measures. Must have a bachelor’s degree in nursing, health care administration, health informatics, or a related field; or, hold licensure as a Licensed Practical Nurse or Registered Nurse. Experience working with patients with mental health issues is preferred.

OTHER SKILLS AND ABILITIES: 

Ability to establish and maintain an effective working relationship with faculty members, staff, patients, and other third parties. Ability to operate computer, keyboard, and printer. Ability to concentrate under high demands and listen effectively. Must have good judgment and problem-solving skills. Knowledge of ICD-10 and CPT coding. Knowledge of health insurance procedures. Ability to organize tasks, work as a team member and/or independently using sound Case Management skills with a variety of professional disciplines.

QUALIFICATION REQUIREMENTS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this job.

EOE/AA/M/F/Disability/Vet

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