The Care Manager – Registered Nurse is responsible for managing Population Health Service Company (PHSC) primary care population for PCP, Post-Acute, and Home Health high risk and/or chronic illness patients via creation of pro-active patient
centered action plans to promote effective education, self-management support, and adherence to the PCP provider's plan of care facilitating access and timely healthcare delivery to achieve cost effective optimal quality and financial outcomes. The essential job duties of this position are:
• Manage Complex High Risk (Chronically ill and/or Medically complex/fragile) patients via Longitudinal Care.
• Prioritize patients via risk stratification tool, providers referrals, inpatient/ER discharge hand offs, and departmental team
• Conduct assessments via EMR review and patient interviews for patient centered action plans that identifies and addresses
barriers to PCP plan of care adherence docum
Valid through: 2020-2-19