Patient Centered Medical Home Manager (43538)

Under general supervision of the Director of Quality Management, the Patient Centered Medical Home (PCMH) Manager is responsible for organizing and supporting the activities of the PCMH community and the Home Health Visit Program, comprised of providers, clinical staff, administrators, community health, and leadership. The Program Manager will work in conjunction with multidisciplinary teams members involved in the care of patients at the Winslow Indian Health Care Center (WIHCC) and will be the main point of contact for PCMH and Home Health related issues of care coordination and administrative tasks. Clinical/medical decisions will remain with the Chief Medical Officer. This will be accomplished by working within established standards for clinical care coordination, case management principles and advance access principles. Ensures delivery of quality health care services in consistent with lawful, ethical and moral principles. Uphold the principles of WIHCC’s Vision, Mission, and Value Statements. Maintains confidentiality of all privileged information at all times.

This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.

Essential Duties & Responsibilities:

• Maintains regular attendance and punctuality.
• Responsible for ensuring clinical care coordination and home health visits are delivered in an appropriate and timely manner for patients and teams;
• Responsible in developing and leading team meetings designed to support obtaining and continually maintaining the PCMH care model and accreditation;
• Responsible for appropriate data gathering, communicating with all stakeholders and will prepare appropriate reports as needed;
• Manage and supervise the clinical care coordinators, home health visit program, and quality management  support staff in the execution of program goals for both health care staff, patients, and the community;
• Assists in the orientation of new personnel to PCMH or the home health program;
• Provides direction and leadership to clinical team members in collaboration with Chief Medical Officer, Quality Management, and Nursing leadership;
• Provides direct patient care, as necessary, in accordance to scope of practice;
• Assures compliance with and ensures timely follow up on daily clinical and coding issues;
• Assist in follow-ups of critical or high priority tests and results, assisting in complete documentation of EHR charts with coordinators;
• Assist in follow up with high-risk patients who were hospitalized or seen in EDs within 48 hours of discharge to assure safe transition.
• Assists in arranging for information exchange with facilities, including after-hours care, LCMC, and FMC.
• Collaborates proactively with all interdisciplinary team members and with a customer-focus to facilitate and maximize patient healthcare outcomes, such as PRC, PAR, PBC, and HIM;
• Coordinates multi-disciplinary patient care conferences for high risk or complex customers as needed;
• Advocates for the customer/family at the service-delivery level and at the policy-making level fostering the patient’s/family’s decision-making, independence, and growth and development;
• Utilizes best practice model to identify, incorporate or develop best practices for PCMH management;
• Monitors and manages GPRA standards for PCMH teams and works with clinical  teams to address concerns;
• Participates in the performance improvement committee and