Job Description

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

The Outpatient Care Manager is responsible for assisting the Care Team (providers, medical assistants, nurses, and additional clinical personnel.) by coordinating care for patients on providers’ daily schedules, and by proactively managing and coordinating care for patients not on the schedule so as to offer complete preventive and/or chronic care for all SLPG patients. This position will act as a primary conduit to provide advocacy, information, and referral services to patients and families to address their medical needs.

JOB DUTIES AND RESPONSIBILITIES:

• Responsible for pre-visit planning; reviews provider schedules and individual patient charts in order to assist the care team to coordinate care for visits and future healthcare needs. Any pre-visit planning should take place one week in advance. Monitors and/or schedules follow-up primary care visits within 48 hours of ED visit, urgent care appointment, or hospital discharge. Responsible for working with patient and patient’ s care team to develop an individualized treatment care plan – including follow-up appointments, labs and other care coordination. Tracks follow-up visits with appropriate specialists for complex patients.
• Communicates with and coaches patients to ensure that they are aware of discharge instructions; have necessary prescriptions; have access to medications and understand how to take the necessary medications, including what to look for regarding adverse events as per their care givers’ instructions.
• Facilitates the information flow between hospitals, long-term care facilities, home health representatives, and the patient’s primary care team.
• Works with providers, clinical staff members, and clerical staff members to help identify high risk, high need patients.
• Assists physicians and other care team members in implementing processes for best practices in preventive services, chronic care and disease management.
• Utilizes the care management model, standards, and scope of practice for care coordination.
• Practices motivational interviewing skills and teach-back skills when interviewing/assessment of patients.
• Utilizes electronic health record, chronic disease registry, and other quality reporting software to capably manage the care of individual patients and populations.
• Works collaboratively with providers and the care team to ensure patient adherence to medical plan of care, including all appropriate preventive and disease-specific screenings, interventions, and treatment goals – including self-management goals and utilization of services goals.
• Identifies, utilizes, and properly directs patients to cultural and community resources.
• Provides in home pulmonary disease and equipment education and assesses for triggers that may exacerbate symptoms. Also, provides pulmonary disease education at the patient’s PCP appointment when appropriate.
• Works with CHW to educate on identifying triggers in the home that may exacerbate symptoms.
• Facilitates Better Breathers Support group.

PHYSICAL AND SENSORY REQUIREMENTS:

Requires sitting, standing, and walking for extended periods of time (up to 8 hours at a time); requires continual use of fingers for typing, writing and electronic handling equipment. Routine use of upper extremities: occasional requirement to left items up to 25 pounds. Regularly requires ability to stoop, bend, reach above shoulder level, and climb stairs. Requires the ability to hear normal conversation and good general, near and peripheral vision.

EDUCATION:

Completion of an accredited Respiratory Therapist program.

TRAINING AND EXPERIENCE:

Respiratory Therapist licensed in appropriate state (PA and/or NJ) required

BLS certification required

CCM certification preferred

Training/experience in Motivational Interviewing and Teachback preferred

Ambulatory Care Management experience preferred

Bilingual – English/Spanish preferred

Electronic Health record documentation experience preferred

Basic high level understanding of Network contract obligations regarding care coordination. Basic high level understanding of governmental and commercial insurance plans and benefits.

Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!

St. Luke's University Health Network is an Equal Opportunity Employer.