Under the direction of department leadership, the Care Manager provides services consisting of comprehensive care management, care coordination and care continuing care services. The Care Manager is accountable for a designated patient caseload/population and plans effectively in order to meet patient needs. The Care Manager is a support to providers and the multidisciplinary in facilitating patient care. The Care Manager strives to enhance the quality of clinical outcomes and patient satisfaction while managing the cost of care.

Essential Job Functions
Assessment
• Conducts initial and ongoing assessments and chart reviews of each assigned patient to identify potential and or actual barriers and care needs.
•Proactively screens and assesses the acuity and transitional needs of each assigned patient
• Engages and collaborates with patients, support systems and the multidisciplinary/healthcare team to establish a plan of care that addresses the mutually identified needs of the patient.

Interventions and Care Coordination
• Demonstrates the ability to interpret clinical information and understand health care treatment and systems.
• Supports patients to ensure they can function to the best of their ability and maintain optimal health related to their medical condition(s). Identifies and addresses gaps in knowledge/understanding/education related to disease management.
• Participates in the patient’s plan of care by interacting/collaborating with patients, support systems, healthcare professionals and community and state agencies. Serves as a liaison between hospital, clinic and community agencies to facilitate the exchange of clinical and referral information.
• Identifies high-risk patients through risk stratification tools and ongoing assessments including ED utilization and hospitalizations to address the medical/psychosocial/financial needs of patients and their support systems in both hospital and ambulatory settings.
• Reinforces goals of care and treatment plans with patients and support systems in order to enhance patient and support system engagement.
• Coordinates care conferences to support effective communication as needed.
• Helps navigate the patient throughout the continuum of care.
• Effectively collaborates and coordinates care with the Social Services Care Manager.
• Maintains current knowledge of community resources and ancillary clinical services to meet the needs of hospital, clinic and regional customers.
• Provides information about available resources to patients and their support systems.
• Partners with the multidisciplinary/healthcare team and the Social Services Care Manager to guide/advocate placement to the appropriate Acute rehab, LTACH, SNF, long-term care facility, assisted living facility, or Home Health Care, in-home services, hospice, ancillary OP services and/or DME as clinically appropriate.
• Acts as a clinical resource to the Social Services Care Manager.
• Understands consultative disciplines and their role in patient care.

Insurance and Utilization Management
• Maintains working knowledge of CMS requirements and readmission penalties.
• Maintains working knowledge of insurance/payer benefits.

Evaluation
• Monitors the need for revisions in the plan of care and makes recommendations to the multidisciplinary/healthcare team when indicated. Modifies the plan of care/goals to reflect changes in patient or their support system status and needs.
• Monitors, evaluates and documents patient progress related to plan of care.

Documentation
• Documents accurately and in a timely manner in the Electronic Medical Record per program guidelines.
• Utilizes standards of professional practice in all documentation and communication consistent with organization/department policy as well as the Board of Nursing and ethical guidelines established and universally supported by the nursing profession.
• Documentation and patient information shall be secured and maintained in accordance with Billings Clinic policy, HIPPA, state and federal guidelines.

Safety/Quality Assurance/Risk Management
• Participates in continuing education, department planning, work teams and process improvement activities
• Maintains current Licensure.
• Adheres to department and organizational policies addressing confidentiality, infection control, patient rights, medical ethics, advance directives, disaster protocols and safety.
• Adheres to department and organizational policies addressing confidentiality, infection control, patient rights, medical ethics, advance directives, disaster protocols and safety.
• Maintains competency in organizational and departmental policies/processes relevant to job performance.
• Utilizes standards of professional practice in all communication with patients, support systems and colleagues consistent with the Board of Nursing and ethical guidelines established and universally supported by the nursing profession.

• Performs all other duties as assigned or as needed to meet the needs of the department/organization.

Outpatient Care Management Specific
• Receives referrals on patients being seen in the clinic (Primary Care, SDC, specialty office, ancillary departments). Coordinates services for medical and non-medical care coordination needs that are episodic or longitudinal.
• Assists patients through care transitions from hospital to home, SNF to home/assisted living, or alternate setting per program guidelines.
• Manages a panel of high-risk patients that require longitudinal education and support.
• Effectively collaborates with Inpatient Care Managers and Social Service Care Managers to address the needs of shared patients.
• Able to function effectively as a part of a team. Utilizing shared knowledge to address complex patient needs.
• Supports Billings Clinic and community-based programs to advance the role of Outpatient Care Management, strengthen partnerships and meet department and patient needs.