Clinical Care Manager

Clinical Care Associates (CCA) is Penn Medicine?s community-based network of primary care and specialty providers. With over 25 Primary Care practices located in and around the Philadelphia area, CCA?s top priority is to provide exceptional, high quality care to all of our patients. To that end, we are building a team of Ambulatory Nurse Care Managers who will work directly with our Primary Care practices to optimize the delivery of longitudinal care management and episodic care management. Patient interactions will be predominantly conducted by telephone; may also include face-to-face and telephonic encounters as appropriate to patient needs. Job responsibilities include:
Support the development and implementation of care management activities for high risk patients such as those who are not meeting desired clinical outcomes, who have frequent hospitalizations or ER visits, and those with uncontrolled multiple chronic conditions in the ambulatory setting.
Develop comprehensive care plans and document progress and interventions in the Electronic Health Record (EHR).
Develop and implement a patient risk stratification model that aims to identify patients with chronic disease who are at risk and may require focused care management support to achieve the patients? optimal health goals.
Collaborate with Data Analyst to create, use, and maintain a care management reporting structure that identifies patients who are likely to benefit from care management services and is able to track the progress of eligible patients who are receiving care management services.
Targeted clinical assessments, medication reconciliation, psychosocial and self-management assessment and support, multi-disciplinary care planning, identification of relevant social determinants of health, and ongoing treatment plan adjustment and evaluation.

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