Work where every moment mattersEvery day more than Hartford HealthCare colleagues come to work with one thing in common Pride in what we do knowing every moment matters here We invite you to become part of Connecticutrsquos most comprehensive healthcare networkThe creation of the HHC System Support Office recognizes the work of a large and growing group of employees whose responsibilities are continually evolving so that we and our departments now work on behalf of the system as a whole rather than a single member organizationWith the creation of our new umbrella organization we now have our own identity with a unique payroll benefits performance management system service recognition programs and other common practices across the systemPosition SummaryThe ICP Community Care Manager is a healthcare professional position working as a member of the ICP Community Care Management team The ICP Community Care Manager facilitates transitions as patients move from one level of care to another ensuring that uninterrupted quality care as well as providing ongoing education and diseased management for ICP attributed patients with chronic conditions They are responsible for providing support and performing duties in a manner that ensures effective and efficient customer service and patient care This position is ideal for someone with a minimum Master of Social Work or minimum Bachelor of Science in Nursing with a healthcare professional background that is passionate about transforming healthcare and assisting patients in meeting their health goalsPosition ResponsibilitiesKey Areas of Responsibilitymiddot Performs transition of care services for ICP attributed patients admitted to acute inpatient settings skilled nursing facilities and other post acute facilitiesmiddot Participates in discharge planning meetings throughout patientrsquos inpatient acuteSkilled Nursing Facility SNFLong Term Acute Care Hospital LTACH stay as appropriatemiddot Partners with inpatient care coordination team to address barriers to discharge including Social Determinants of Health needs other biopsychosocial related needs andor healthcare related barriers while also providing timely communication back to the patientrsquos primary care providermiddot Collaborates with other HHC system partners upon patientrsquos discharge from acute inpatient skilled nursing facility and other post acute facility setting to the communitymiddot Partners with Skilled Nursing Care Coordinators Resource Coordinators ICP Clinical Pharmacists Primary Care Behavioral Health Clinicians and homecare partners to support patients across the care continuummiddot Reviews and identifies at risk patients ED utilization high risk score care gaps etc for proactive outreach and longitudinal care managementmiddot Collaborates with patient caregiver providers and additional care team members to develop longitudinal plan of care including development of a care plan appropriate referrals and community supportsmiddot Identifies resources within HHC system and larger community to address patient care needsmiddot Provides education for patients families community and other professionals regarding disease prevention impact of illness and advocacy for benefits and health maintenancemiddot Participates in continuous improvement opportunities through workgroups collaborative pilots and system initiative councils Contributes to ongoing development of the care management model across the continuum through valuable input and constructive feedbackWorking RelationshipsThis Job Reports To Job Title Manager Care ManagementExternal External customers of Integrated Care Partners system based clinical positions requiring support of ICP Clinical teamWork where every moment mattersEvery day more than Hartford HealthCare colleagues come to work with one thing in common Pride in what we do knowing every moment matters here We invite you to become part of Connecticutrsquos most comprehensive healthcare networkThe creation of the HHC System Support Office recognizes the work of a large and growing group of employees whose responsibilities are continually evolving so that we and our departments now work on behalf of the system as a whole rather than a single member organizationWith the creation of our new umbrella organization we now have our own identity with a unique payroll benefits performance management system service recognition programs and other common practices across the systemPosition SummaryThe ICP Community Care Manager is a healthcare professional position working as a member of the ICP Community Care Management team The ICP Community Care Manager facilitates transitions as patients move from one level of care to another ensuring that uninterrupted quality care as well as providing ongoing education and diseased management for ICP attributed patients with chronic conditions They are responsible for providing support and performing duties in a manner that ensures effective and efficient customer service and patient care This position is ideal for someone with a minimum Master of Social Work or minimum Bachelor of Science in Nursing with a healthcare professional background that is passionate about transforming healthcare and assisting patients in meeting their health goalsPosition ResponsibilitiesKey Areas of Responsibilitymiddot Performs transition of care services for ICP attributed patients admitted to acute inpatient settings skilled nursing facilities and other post acute facilitiesmiddot Participates in discharge planning meetings throughout patientrsquos inpatient acuteSkilled Nursing Facility SNFLong Term Acute Care Hospital LTACH stay as appropriatemiddot Partners with inpatient care coordination team to address barriers to discharge including Social Determinants of Health needs other biopsychosocial related needs andor healthcare related barriers while also providing timely communication back to the patientrsquos primary care providermiddot Collaborates with other HHC system partners upon patientrsquos discharge from acute inpatient skilled nursing facility and other post acute facility setting to the communitymiddot Partners with Skilled Nursing Care Coordinators Resource Coordinators ICP Clinical Pharmacists Primary Care Behavioral Health Clinicians and homecare partners to support patients across the care continuummiddot Reviews and identifies at risk patients ED utilization high risk score care gaps etc for proactive outreach and longitudinal care managementmiddot Collaborates with patient caregiver providers and additional care team members to develop longitudinal plan of care including development of a care plan appropriate referrals and community supportsmiddot Identifies resources within HHC system and larger community to address patient care needsmiddot Provides education for patients families community and other professionals regarding disease prevention impact of illness and advocacy for benefits and health maintenancemiddot Participates in continuous improvement opportunities through workgroups collaborative pilots and system initiative councils Contributes to ongoing development of the care management model across the continuum through valuable input and constructive feedbackWorking RelationshipsThis Job Reports To Job Title Manager Care ManagementExternal External customers of Integrated Care Partners system based clinical positions requiring support of ICP Clinical teamRequirements and SpecificationsEducationmiddot Minimum Master of Social Work MSW or Bachelor of Science in Nursing BSN middot Preferred Licensed Clinical Social Worker LCSW Social Work Licensure or Master of Science inNursingMSNLicensure Certification Registrationmiddot Minimum Accredited Case Manager ACM or Commission for Case Manager CCM Certificationmiddot Preferred Mental Health First Aid Certification within st year of hireLanguage Skillsmiddot Minimum Able to read speak write Englishmiddot Preferred Ability to communicate in other languages highly desirableKnowledge Skills and Ability Requirementsmiddot At least five years of experience working in a healthcare setting and at least two years of experience in case coordinationcare management middot A passion for helping vulnerable populations by managing patients across the care continuummiddot Knowledge of chronic disease education and support of complex patientsmiddot Awareness in supporting patients on accessing community resourcesmiddot Knowledge of medical terminology as well as ACO payment models utilization management and healthcare reform topicsmiddot Willingness to develop new skills and ability to receive feedbackmiddot Positive customer focused approachmiddot Proven ability to work effectively independently as well as in a team environmentmiddot Must be comfortable and flexible with ambiguity and change processesmiddot Excellent written and verbal communication skills middot Strong organization skills and attention to detailmiddot Establishes and maintains effective work relationshipsmiddot Displays courtesy and helpfulness when interacting with all internal and external customersmiddot Proactively takes action to achieve goals beyond what is required or assignedmiddot Adheres to HIPAA requirementsmiddot Adheres to Hartford Healthcare policies and standards of service as well as those of practices being supportedmiddot Physical abilities to include sitting and standing for prolonged periodsmiddot Must attend and pass examination for Mental Health First Aid Certification within first year of hireWe take great care of careersWith locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge ndash helping to bring new technologies breakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure worklife balance Every moment matters And this isyour momentRequirements and SpecificationsEducationmiddot Minimum Master of Social Work MSW or Bachelor of Science in Nursing BSN middot Preferred Licensed Clinical Social Worker LCSW Social Work Licensure or Master of Science inNursingMSNLicensure Certification Registrationmiddot Minimum Accredited Case Manager ACM or Commission for Case Manager CCM Certificationmiddot Preferred Mental Health First Aid Certification within st year of hireLanguage Skillsmiddot Minimum Able to read speak write Englishmiddot Preferred Ability to communicate in other languages highly desirableKnowledge Skills and Ability Requirementsmiddot At least five years of experience working in a healthcare setting and at least two years of experience in case coordinationcare management middot A passion for helping vulnerable populations by managing patients across the care continuummiddot Knowledge of chronic disease education and support of complex patientsmiddot Awareness in supporting patients on accessing community resourcesmiddot Knowledge of medical terminology as well as ACO payment models utilization management and healthcare reform topicsmiddot Willingness to develop new skills and ability to receive feedbackmiddot Positive customer focused approachmiddot Proven ability to work effectively independently as well as in a team environmentmiddot Must be comfortable and flexible with ambiguity and change processesmiddot Excellent written and verbal communication skills middot Strong organization skills and attention to detailmiddot Establishes and maintains effective work relationshipsmiddot Displays courtesy and helpfulness when interacting with all internal and external customersmiddot Proactively takes action to achieve goals beyond what is required or assignedmiddot Adheres to HIPAA requirementsmiddot Adheres to Hartford Healthcare policies and standards of service as well as those of practices being supportedmiddot Physical abilities to include sitting and standing for prolonged periodsmiddot Must attend and pass examination for Mental Health First Aid Certification within first year of hireWe take great care of careersWith locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge ndash helping to bring new technologies breakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure worklife balance Every moment matters And this isyour moment