Manager, TCHP Care Coordination

The primary duty of this position is to manage the Care Manager, Care Coordinator and social Work roles related to continuity of care across the healthcare continuum. The manager will oversee the Care Managers, Care Coordinators and Social Workers in their population health efforts. The manager will develop workflow, training, develop tools and resources and evaluate the progress and quality of the work effort. The manager will work closely with physicians, the director and office managers in the oversight of care coordination in the TCHP Primary Care practices. The manager will be involved with the project development, standardization, implementation and ongoing enhancements.  The manager will be responsible for hiring, development and management of all staff roles. The manager will be responsible for maintaining the departmental budget at or below target.

Care Management and Care Coordination - Work with all clinical teams as a resource on care management 

• Provide support and act as a resource to Care Managers, Care Coordinators and Social Workers

• Manage schedules/payroll

• Identify barriers to efficient work flows and work collaboratively to develop action plans for improvement

• Assist with Identification of targeted patient populations that would benefit from care management.

• Assist with Pre-visit planning workflow to ensure care completion prior to visit whenever possible

• Develop workflow to coordinate patient care services for selected patients across the continuum of care through collaboration with the patient and family and health care providers in achieving optimal patient outcomes

• Develop a robust orientation program to integrate new staff into roles

• Develop ongoing training to educate staff on management of disease processes, self management and treatment protocols. 

• Develop patient engagement strategies and collaborate with internal and external resources to train staff in use of motivational interviewing, teach back and other evidence based techniques. 

• Develop self management tools and resources to facilitate improved health outcomes

• Identify and develop those staff members that are potential leaders.

 

Clinical quality and performance

• Assist director and quality manager in evaluating outcomes and participate in process improvement projects.

• Works closely with providers as well as clinical staff to assure clinical quality is an ongoing priority in all phases of patient care.

• Participates in clinical quality activities and facilitate implementation of clinical best practices.

• Network/collaborate with professional colleagues and outside community agencies to develop best practices.

• Coordinate with physician leadership to develop strategies for the high risk patient population to coordinate patient care from.

• Monitors utilization of resources and collaborates with the patient and care team to promote efficient and appropriate use. 

• Provides leadership in the development of office workflows, collaborating with physicians on the development of care standards with preventative services and chronic disease management.

• Leads health care team by influence and role modeling integrated effective nursing practices, excellent customer service, innovation and providing outstanding support for the physician practice.

• Ensure safe practices   and report any concerns

• Assists with regulatory reporting to CMS for CPC+ program

• Participates in CPC+ All Day Learnings activities and webinars with regional learning faculty.

 

Customer Service

• Promote excellence in healthcare delivery for the patient and/or patient family.  Identify and facilitate implementation of clinical best practices.

• Engages staff to utilize patient centered communication strategies and treat patients in a positive and   respectful manner

• Shows respect and sensitivity for differences among staff,  co-workers and patients

• Facilitate seamless patient experience by coordinating care with the care team, patient and family.

• Assist Care Managers, Care Coordinators and Social Workers  with customer service issues

• Ensure staff engaged in patient satisfaction improvement activities. 

• Assist staff in coaching techniques

 

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