Clinical Care Manager

Clinical Care ManagerPenn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines. Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?Entity: CCA-Penn Primary Care and Penn Specialty PracticesDepartment: Penn Partners in Care 2Location: Bala CynwydHours: FT- Remote EligibleJob Summary:The Clinical Care Manager is responsible for promoting organizational values of patient and visitor satisfaction by demonstrating courtesy and respect for families, visitors and other employees. Collaborates with practices and actively provides clinical support to "high-risk" patient populations for multiple practices - in all age groups ranging from young adulthood through geriatrics. Demonstrates competence in the assessment, treatment and care of patients serviced. Will include travel, telephone or telehealth encounters as appropriate to patient needs.Accountabilities:• Designs and implements care management support activities for high risk patients with chronic diseases and high medical service utilization.• Collaborates with physician and practice staff in identifying appropriate patients for care management utilizing established criteria. Collaborates with the patient and provider to establish and implement a care management plan using evidence-based guidelines. Develops patient objectives and measures progress according to standards of care.• Triages patient telephone calls and provides consultation regarding ongoing symptom management resulting from treatment and disease, analysis of intervention regarding diagnostic work-up, assessing and managing acute emergencies, managing family concerns as needed, liaison activities with affiliated physicians, nurses, pharmacists and emergency rooms.• Initiates appropriate evaluation and management of emergency situations.• Coordinates patient’s management/treatment plan throughout the institution.• Instructs patient/family regarding medications and treatments. Educates patients regarding health and illness prevention. Recommends community resources to meet patient and family needs. Develops patient education programs.• Creates, uses, and maintains patient-specific care management tracking system that identifies/ reports on patients who will benefit from care management services, the subsequent patient progress, and associated interventions.• Supports QA and maintenance efforts for patient registries and quality reporting. Works with the Clinical Analyst to summarize and analyze data from registries.• Promotes patient self-management and empowers patient and families to achieve optimal health outcomes. Assists patient to identify and/ or develop and utilize their support systems.• Evaluates the effectiveness of care management plan in meeting established care goals and revises the plan as needed to reflect changing needs, issues and goals.• Prepares and maintains appropriate documentation as required.• Collaborates with all members of the health care team to resolve patient health, social or behavioral health needs.• Provides monitoring and continuity of care between physician visits. Maintains and reviews patient records, charts and other pertinent information.• Performs duties in accordance with Penn Medicine and entity values, policies, and procedures. Other duties as assigned to support the unit, department, entity, and health system organization.Qualifications:Associates Degree in NLN- approved school of nursing requiredBachelors Degree in nursing and 1+ years prior nursing experience in internal/family medicine and care management experience preferredLicenses/Registrations/Certs:Active PA or NJ RN license based on position location. Dual (NJ & PA) RN licensure required within 3 months of Hire requiredWe believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives. Live Your Life's WorkWe are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.