Under the direction of the ACO Executive Director and Medical Director, the Care Manager for the ACO will follow a collaborative process to assess, plan, implement, coordinate, monitor and evaluate the options and services available to meet an individual’s health needs. The Care Manager for the ACO is responsible for the identification, evaluation and coordination of health care services provided to the ACO members.
Essential Functions and Responsibilities of the Job
Strong verbal and written communication skills
Ability to complete work independently and collaborate with internal and external team members and participate in ACO and/or related meetings, committees or functions
Computer literacy with ability to work within several internal and external on line and Web based systems, reports and analytics
Basic Math Skills
Understanding of privacy and HIPAA standards
Flexibility and multi-tasking skills
Be at work and be on time
Follow company policies, procedures and directives
Interact in a positive and constructive manner
Prioritize and multitask
Essential Job Outcomes
Identifies and evaluates members for enrollment into one of the ACO Care Management programs through the following mechanisms:
a) Physician referral
b) High-risk screening tools
c) Ambulatory utilization
d) Inpatient concurrent review (acute/sub-acute)
e) Diagnosis screening criteria
f) Family Member/significant other referral
g) Data analysis reports
Assesses, plans, implements, coordinates, monitors, and evaluates health services with the goal of optimizing the member’s health status.
Integrates evidence-based clinical treatment guidelines, preventive guidelines, protocols, and quality metrics in the development of treatment plans
Develops care plans that are patient-centered, promoting efficiency, access and quality in the delivery of healthcare for the ACO members.
Develops systems of care that monitor member progress and promote early intervention when healthcare needs or gaps in care are identified
Works effectively with other members of the health team to optimize interventions; coordinating health care services with physicians, facilities, contracted providers, and ancillary providers; acting as liaison between member, HealthCare Team, community programs and services and the Memorial Health Systems medical leadership.
Manages utilization and practice metrics to further refine the delivery of care model to maximize quality, clinical, and fiscal outcomes for the ACO population.
Collects and analyzes health services data, including but not limited to emergency care utilization, care gap opportunities, admission and readmission reports to identify which members need care coordination and post-acute care management.
When applicable, refers members to and collaborates with appropriate health plan retained functions in Care Management including; Transplant, Transgender Reassignment Surgery, Bariatric Surgery, Complex Newborn/NICU, Eliza (IVR Warm Transfer), Behavioral Health, Investigational/Experiment services, Benefit Substitution Period, Out of Area care.
Position success measures include
Understands the position as role-model for caring and compassionate decision making
Finds opportunity in barriers and challenges
Has continuous learning approach to business and medicine
Supports the organizations goals and mission statement
Is dedicated to the delivery of high-quality patient care and service
Acts as resource for department staff, inter-departmental staff, contracted physicians, health plans, contracted facilities, members/families and ancillary providers.
Attends and participates in patient care conferences and or related ACO meetings as necessary