Community Complex Care Manager

About the position

At AbsoluteCare, we serve the most vulnerable individuals in America. These are our neighbors, people who are at higher risk for disease or who have multiple, complex, chronic illnesses. Often, they deal with an unequal healthcare system and wind up seeking basic care from emergency rooms. We take these patients out of those spaces and turn them into members: people who are entitled to some of the best, most focused care this country has to offer. We call this 'care beyond medicine.' We have turned the doctor's office into a comprehensive care center. Here, we surround our members with a core care team of doctors, nurses, social workers, and medical assistants who have the time and skills to get to know our members' needs. We make the most important services available to our members under one roof. This includes a pharmacy, X-rays, a blood lab, nutrition services, urgent care, and much more. We don't stop at our four walls. We engage members in the communities where we all live to find the people who need us most. Through these community care teams, we remove the barriers to healthcare that so many people face daily. And it works. Our unique care is guided by our core values of accountability, caring, trust, and teamwork. We call it ACT 2.

Responsibilities

• Meet with community primary care providers on a regular basis and review assigned member care plans and ongoing health needs.
• Attend member visits at their primary care provider or specialist office appointments and provide follow-up support for care coordination needs.
• Complete comprehensive assessment and person-centered care plans (PCCP) for each member on the assigned caseload.
• Manage person-centered care plans and member contact in compliance with all agency requirements, internal protocols, and accreditation standards.
• Develop, implement, and maintain person-centered care plans using SMART goals.
• Maintain up to date PCCPs in the electronic health record, including objective measures to track progress required to successfully track and complete treatment plan goals.
• Provide education with teach back regarding medical, behavioral, and functional health conditions, symptoms, and treatment options.
• Provide evidence-based clinical interventions centered on established person-centered care plan goals using a variety of approaches, e.g., trauma informed care, harm reduction, behavior change modalities, motivational interviewing, teach back methods and problem solving.
• Meet established Key Performance Indicators.
• Manage assigned caseload based on contact frequency requirements and utilization data.
• Proactively mitigate/resolve barriers to care to increase adherence to treatment plan.
• Collaborate with the ICT to update the team on member progress and needs and provide CCM recommendations for members to stabilize health and overcome barriers to social determinants of health.
• Assist members in accessing and engaging with services and resources.
• Maintain schedule in the clinical system and document all interactions within 1 business day.
• Actively participate in required meetings.
• Follow up on member compliance to service or resource referrals.