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Population Health Care Manager  

Category Clinical Services  

The Population Health Care Manager is responsible for evaluating patient risk, identifying gaps in care, coordinating in-bound/out-bound referrals/authorizations and care transitions, and developing and updating a comprehensive 'whole-person' care plan based on a comprehensive assessment of each patient, while consulting with the patient, caregiver(s), family, legal guardian(s), primary care provider (PCP), psychiatrist, and other key providers and specialists. This role will perform chronic disease management, assessment of disease, care plan development and facilitation, referral to appropriate levels of care, etc. The role functions as an integral part of an interdisciplinary team, ensuring excellence with transitions of care to achieve optimal clinical outcomes through a seamless model of access and care. Focus on improving the health status and care for individuals with chronic conditions with complex medical, mental health and psychosocial issues.

Duties and Responsibilities

  • Coordinate and facilitate timely implementation of assessments, care plans, and appropriate interventions to determine patient health, social situation, physical environment, mental health, substance use, expressed trauma, economic status, and education to patients while exercising discretion and independent judgment; following established policies and procedures (Note: This is a new role that will be involved in the development and documentation of policies and procedures related to care management).
  • Provide individual treatment to address barriers and identified concerns by accessing systematically identified data from multiple sources such as patient medical records, claims, and program metric reports to target recipient(s) and provider(s) for outreach, education, and intervention.
  • Perform targeted interventions to assist patients with connection to primary care and other health care resources.
  • Involve the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process.
  • Use a patient-centric, collaborative partnership approach to assist the patient with improved self-management and identifying barriers by addressing the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs.
  • Utilize proven processes to measure a patient's understanding and acceptance of the proposed plan(s), his/her willingness to change, and his/her support to maintain health behavior change. Apply teaching and learning theories to assist patients and families with the physical and emotional impact of body changes and chronic illness. Monitor quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s).
  • Electronically document all activity in the EMR in a timely fashion including the maintenance of up-to-date care plans and medication lists.
  • Communicate and coordinate with all provider(s) and member(s) of the care team as needed to minimize fragmented care and foster appropriate utilization of services. This will include navigating transitions of care, generally from hospital to home or community facilities.
  • Facilitate interdisciplinary communication to include peer support, specialists, PCP, psychiatrist, and other key providers.
  • Interface with discharge planners, social workers, therapists, physicians, psychiatrists, public health and social service departments, as well as mental health/substance use agencies and other community resources, to assure that patients are linked to and engaged in services.
  • Provide on-site, community, and telephonic outreach to patients, providers, and community stakeholders assisting with identification of treatment history, diagnoses, and patient care components both internally and externally to ensure that services provided are sensitive to the needs of individual patients and take into account ethnic and cultural backgrounds. This position may require home visits based on business rules and the clinical needs of the identified patient population.
  • Provide feedback to management and executive leadership that will enhance negotiations with payers, improve care management, and/or addresses gaps in care.
  • Develop and maintain positive relationships with customers internal and external to Easterseals UCP.
Position Requirements

Education and Experience

  • Bachelor's degree in a clinical field such as Nursing, Counseling, Social Work, Therapy, Allied Health, or community health-related fields.
  • 3 years of clinical experience required, including one year of care management.

Degrees, Licensures, Certifications

Must have a current license in at least one of these areas: current or compact RN licensure in the state of North Carolina, current licensure as a licensed clinical social worker by the NC Social Work Certification and Licensure Board, current licensure as a Licensed Professional Counselor by the state of NC, or current licensure as a Licensed Addiction Specialist by the state of North Carolina. Requires ACM or CCM certification within 3 years of hire date.

Full-Time/Part-Time Full-Time  
Shift -not applicable-  
Position Population Health Care Manager  
Division Clinical  
Exempt/Non-Exempt Non-Exempt  
Location Clinical Raleigh  
About the Organization Easterseals UCP has been part of the fabric of North Carolina and Virginia for 75 years. We started in counties all over NC and VA filling gaps and addressing the needs of children and adults with disabilities. Our legacy organizations Easterseals NC, United Cerebral Palsy NC, and Easterseals Virginia joined forces as Easterseals UCP to intentionally work side-by-side with more than 20,000 individuals and their families, providing the broad network of services and support they need to achieve better days. Today we are affiliated with both Easterseals, Inc. and United Cerebral Palsy Inc.

Our mission is to create opportunities, promote individual choice, and change the lives of children and adults with disabilities by maximizing their individual potential to live, learn, work and play in their communities.
EOE Statement We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.  
SuperVFlg None Specified 

HoursPerWk None Specified 

This position is currently accepting applications.

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