Disease Management Disease Manager
Demonstrates clinical expertise through direct or indirect care. As a collaborating member of the health care team provides pre-visit and follow-up direction and support to the patient, family, and health care providers. This position aids in addressing ethical and legal concerns including end-of-life care and complex disease management. The responsibilities will include: supporting the continuum of care from the acute to the patient-centered medical home, aiding in the development of office workflows for the medical home, and collaborating with physicians to develop a standard of care with preventative services and chronic disease management.
The position will participate in clinical quality activities and facilitating implementation of clinical best practices across the continuum. The position will develop relationships with professional colleagues within the medical neighborhood to enhance the interdisciplinary team and the services it provides as well as providing follow-up contact with patients as indicated to ensure compliance with recommendations – medications, lab/x-ray, specialist visits, PCP visits, dieticians, etc. The position will be responsible for ensuring patient compliance with quality measures at the practice level and assessing barriers to compliance and coordinating initiatives to support patient compliance. Providing telephone advice per protocol, handling urgent calls and emergent calls. Anticipating the needs of the patient population and seeing that necessary documentation and pre-visit planning is completed before patient visit within the medical home arena.
Benefits
Minimum Education
Minimum Work Experience
License and Certification
1) This is a Hybrid Position (3 days on site and 2 days' work from home). This could change at any time based on business needs 2) Complete comprehensive risk assessment on members 3) Complete monthly care plans for members who have been identified as High Risk 4) Assure appropriate plan of care is created and documented for the member, ensure that the plan of care is appropriately communicated and understood by the care team. 5) Assist member with any SDOH issues that may arise 6) Streamline transition in and out of the hospital 7) Schedule follow-up appointments after inpatient discharge and/or ER visits 8) Completing yearly Health Risk Assessments on all members 9) Develop effective working relationships with PCPs, Specialists, care team members, Administrative Leadership and Physician Champion 10) Address all chronic conditions assessments 11) Present case reviews monthly during the weekly huddles 12) Develop and maintain excellent working knowledge of disease management/care manager/health coaching skills and systems; stays abreast of current/upcoming enhancements to this field of knowledge; maintain excellent knowledge of disease state assigned 13) Attend trainings that are required through this program 14) Must be proficient in Excel 15) Excellent computer skills
Disease Manager/ Care Manager • 1500 S. California Avenue, Chicago, IL
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