Older Adult Case Manager

Make a difference every day at Amoskeag Health, where we believe strong healthcare begins with strong human connections! Who You Are: Amoskeag Health is seeking a full-time Older Adult Case Manager (OACM) who supports patients aged 65 and over in meeting their health goals, living their best life and managing their chronic conditions. You collaborate and maintain a continuous partnership with chronically ill or high-risk elderly patients and their family/caregiver(s), the Amoskeag Health integrated care team, specialty providers and staff, and community resources. You will assist in the development of patient-centered care plans that are based on evidenced-based practices and protocols, assesses patient needs and abilities and implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patients health status and ensuring the delivery of quality, efficiency, and cost-effective health care services. What You'll Do: Assesses patients unmet health and social needs and actively assists in resolving them so the patient can live independently as long as possible.Develops a care plan with the patient, family/caregiver(s) and providers that increases patients ability for self-management and shared decision-making.Maintains accurate and timely documentation in the electronic medical record of assistance and services provided.Registers appropriate patients in the Chronic Care Management program, completing related paperwork with patient, and submitting charges for billing when allowed by third party payers or grant funding.Meets with program patients monthly for review of overall status, medication adherence and progress on health goals. Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed. Some home visiting is required.Serves as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.Coordinates timely patient access to appropriate medical and specialty providers. Supports primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding care transitions and referrals.Facilitates and attends meetings between patient, family/caregiver(s), care team, payers, and community resources as needed. Makes home visits to patients home as necessary.Works to increase patient utilization of preventative care and reduce emergency room utilization and hospital readmissions.Increases patient and family comprehension of care plan by providing culturally and linguistically appropriate education and care. Assists in building patient and family/caregivers health literacy skills and ability to navigate services and resources independently.Tracks patient progress on self-management goals and progress with service coordination efforts for high-risk patients and facilitates transition of patients to the Practice Care Team Nurse when appropriate. Documents care and progress in Amoskeag Healths electronic medical record (EMR).Collaborates on the development of workflow, procedures, processes, and data collection to include key metrics for department performance, billing and grant reporting.Identifies current and potential relationships with referral agencies and maximizes those relationships.Provides clear written and oral communication to both Amoskeag Health patients and employees.Attends and participates in meeting requirements of Amoskeag Health and funding sources. This may include, but is not limited to assisting with development, implementation and monitoring of grant proposal. If absent, responsible for reading of minutes and signing the documentation.Works autonomously and is accountable for responsibilities. Requests input, feedback, and clarification whenever necessary to facilitate positive working relationships with supervisor, providers, other staff, and community resources.Reviews the current literature regarding effective care coordination, effective engagement and communication strategies, care management strategies and behavior change strategies and incorporates into clinical practice and day to day department efficiency and care excellence.