Integrated within the Physician Practice/Medical Home setting the Care Manager is involved in coordinating patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care, in the right place, at the right time.
The primary responsibility of this position is the development and oversight of the system care management development program for population health assuring the implementation of evidenced based, core and consistent care management practices across the system, which includes determining role functions and competencies.
Manage new customer programs, development projects, and other types of internal projects to ensure projects and programs are completed in accordance with well-defined goals (performance, timing, quality, and cost).
Assessment of patient care needs, formulating plans of care, implementing patient care, assessment of care effectiveness, communication of plan of care, delegation / supervision of care tasks, and documentation of care provided.
Provides a variety of direct services and clinical interventions in order to provide continuity of care and to help patients and families resolve socio-emotional problems associated with adjustment to illness, resource needs, mental health problems and a variety of life events and transitions.
Provides input to the Breast Advisory and Lung Advisory Committees in the development of quality assurance programs that include tracking information, care conference presentations, outcome measures and patient satisfaction indices.
The Performance Improvement Specialist is responsible for co-developing, implementing, and managing outcomes-driven projects ("workstreams") focused on advancing Triple Aim objectives outlined by Berwick, Nolan, and Whittington -- Improving the experience of care, improving health status, and lowering the cost of care.