Outpatient Care Manager

Position Summary

At Stony Brook Medicine, a TH Staff Associate/Outpatient Care Manager is a valuable member of our team, who provides clinical services to our patient population.  Qualified candidates will demonstrate superior patient care and possess outstanding communication skills while adhering to our high standard of excellence.

Duties of an Outpatient Care Manager may include the following but are not limited to:

• Documents in the EMR the initial patient functional and medical assessments and ongoing plan of care.
• Facilitates communication and coordination among members of the healthcare team in the care planning process.
• Engages with patients and their family, and members of the health care delivery team about goals of care and the care plan.
• Actively participates with insurance company and physician to provide authorizations for clinical and all potential medical interventions. 
• Demonstrates an understanding of managed care trends, payer regulations and Medicare/ Medicaid criteria for services.
• Active participation in performance improvement, department activities and data collection efforts.
• Provide proactive health care for geriatric patients with multiple chronic conditions and complicated health care needs.
• Work closely with patient’s PCP to provide collaborative care for 50-60 chronically ill patients.
• Monitor and promote self-management. 
• Facilitates transitions of care by contacting patient within two business days of discharge and completing a templated note that assures patient understanding of medications, care plan.
• Arranges for home telemonitoring, where applicable.  Assures that patient has received necessary services and medical supplies and equipment.
• Serves as an office liaison to outside nurses for patients on home telemonitoring.
• Maintains active spreadsheet of patients enrolled in care management. Monitors patient panel for admissions/discharges.
• Tracks high risk COVID patients in the practice and assures timely follow up.  Makes certain patients are aware of “red flags” of when to call the doctor or go to ER.
• Performs comprehensive home assessment. Creates patient/family centered plan of care covering important chronic medical and geriatric conditions per evidence based clinical practice and PCMH guidelines. Provides agreed upon individualized action plan.
• Monitors and assesses patient outcomes with phone encounters at a minimum of once monthly. Documents changes in plan of care in EMR and alerts primary care team members.
• Provides education on chronic clinical medical conditions and outpatient resources to support patients, patients’ families and all caregivers.
• Recognizes level of care needs, community resources, and insurance benefits, so that appropriate referrals and resource linkages can be made to support ongoing self-care needs.
• Reviews labs and alerts medical providers with abnormal findings, assists with Coumadin management and medication reconciliation.
• Triage patient phone calls and troubleshoot medication management issues
• Adheres to all SBUH policies and procedures
• Always maintains a high level of customer service.
• Participates in special projects or other duties as assigned.

Qualifications

Required:  

• RN Licensure in NY State
• Outpatient community service experience
• Experience working with geriatric patients in transitions of care
• Bachelor’s Degree with at