Clinical Case Manager

SUMMARY
Under the direct supervision of the Clinical Care Team Supervisor, the Clinical Case Manager works with patients referred for assistance in accessing and utilizing health care resources due to their complex chronic illness. Clinical Case Manager will assist patients with disease education and self –management skills.

ESSENTIAL JOB FUNCTIONS including the following. Other duties may be assigned. Identifies the targeted high risk patient population within practice site per PCP referral, risk stratification and patient lists.
Carry an average case load of 150 patients.
Determines patient’s willingness and readiness to work with case management.
Assesses over time the health care, educational, and psychosocial needs of the patient/family and increase case management support during crises.
Coordinates care and educate patients to build trust between patients and medical practitioners, and enhancing communication and the continuity of care.
Consults with other health care team members to coordinate the services of patient education, preventive care and disease management and eliminate barriers.
Collaborates with Muskegon Family Care providers and staff to carry out the goals and objectives of MFC in accordance with established plans, policies, and procedures.
Collaborates with all departments on needs for selected patients (Diabetes, Hypertension, Depression, Asthma and Chronic Pain).
As needed, meets with patients to review medications, address compliance and refill medications (possibly by phone or face-to-face joint visits).
Documents pertinent case activities and findings in a timely and accurate manner.
Acts as an advocate for patient’s health care needs.
Maintains clinical tracking data on chronic disease patients.
Communicates with each provider to determine best choice to relay recommendations (reminder message vs. other).
Provides appropriate resources for selected patients.
Assists with transition of care.
Assists with Lorenz report data collection.
Works with health Coach for individualized patient plans.
Refers to appropriate MFC programs when needed (BH, MATS, Cooking Class, and Gardening Club).
Responsible for educating current/active patients on in the following:  (1) Diabetes; (2) Hypertension; (3) Depression; (4) Asthma; and (5) those on schedule II medications (i.e. Norco, Methadone, Adderall).
Regular and prompt attendance at work.
All other duties as assigned.

QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Muskegon Family Care requires all team members, including temps, contractors, interns, residents, students, etc. to receive the COVID-19 vaccination subject to certain exclusions. Muskegon Family Care is committed to granting reasonable accommodations in accordance with applicable laws.