The Care Manager delivers telephonic care management for Curana patients enrolled in a Value-Based Care Program such as but is not limited to Advanced Primary Care Management (APCM) or Chronic Care Management (CCM)
Working with Curana Providers and the interdisciplinary team, the Care Manager supports quality, cost-effective care
Review electronic health records (EHR) to identify gaps in care for patients residing in a Long-term Care Nursing Facility
Review and approve initial and ongoing health questionnaires completed by a member of the care management team
Serve as a health coach to educate patients and/or caregivers about their disease process
Develop patient-centered care plans
Educate patients and their durable medical power of attorney (DPOA) on the benefits of APCM or CCM
Support quality gap closure through clinical discovery
Schedule Provider visits for at-risk patients
Coordinate with the Transitional Care Manager to schedule patient visits and inform the TCM nurse if a patient is discharged to acute or SNF
Ensure orders, referrals, and prior authorizations are facilitated by the virtual care support team
Escalate abnormal diagnostic test results to Curana providers
Communicate patient health updates to the Curana providers
Communicate treatment plans and health updates to the patient’s caregiver in an effective and caring manner
Primary liaison between the provider and administrative support team.
Requirements
Must hold an active, unrestricted compact LPN license
Ability to obtain additional state licenses, as needed
2+ years of experience in nursing is required
Care settings may include inpatient, outpatient, or skilled nursing facilities
Exhibits knowledge of pathophysiology and accepted treatment protocols for common health diagnoses (i.e., diabetes, chronic heart failure, chronic obstructive pulmonary disease)
Ability to analyze patient records to identify gaps in care and report to the provider
Ability to work in a remote environment that is free of distractions
Proficient computer skills and ability to adapt to various technology platforms
Excellent written communication skills
Demonstrated experience in the usage of clinical data to guide decision making
Must have the ability to function independently and as a member of the interdisciplinary care team.