Population Health Care Manager - Days

Duties and Responsibilities

Remote Work Capable

Essential Functions:

• Utilizes Motivational Interviewing as a patient-centered technique to promote self-management of chronic conditions and improve long-term outcomes.
• Maintains a caseload of patients per department guidelines and conducts outreach according to established protocols.
• Engages patients in home, primary care offices, and other community settings as appropriate.
• Identifies, enrolls, and manages patients in Complex Care Management programs.
• Conducts Transitions of Care and proactive outreach for high-risk patients and ensures appropriate follow-up via care management, or technology.
• Develops, implements, and updates individualized care plans to optimize health outcomes and promote wellness.
• Performs medication review and uses teach-back methods to confirm patient understanding and adherence.
• Collaborates with PCPs, specialists, and hospitalists to coordinate and implement patient-centered care plans.
• Initiates and tracks referrals to internal services and community resources to support care goals.
• Provides resource management to ensure the right care is delivered at the right time and place, optimizing cost and experience.
• Assists patients in navigating personal health decisions and care preferences, including but not limited to Advance Care Planning, to ensure individualized support and goal-aligned care.
• Documents assessments, care plans, goals, and interventions in the electronic health record per accrediting body and departmental standards.

Common Expectations:

• Prepares and maintains appropriate documentation as required, while maintaining established policies and procedures, objectives, quality assessment and safety standards.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
• Attends meetings as required.

Physical Demands:

• Standing - Occasionally
• Walking - Occasionally
• Sitting - Frequently
• Reaching - Rarely
• Talking - Frequently
• Hearing - Frequently
• Repetitive Motions - Occasionally
• Eye/Hand/Foot Coordination - Occasionally

Working Environment:

• Occupational Hazards - Occasionally

Travel Requirements:

• Estimated Amount: 10% - Travel required. Makes home visits.