Integrated Care Manager

Integrated Care Manager

The Integrated Care Manager is primarily responsible for overseeing Care Navigators and managing patients who are considered high risk. This position promotes effective education, self-management support and timely healthcare delivery to achieve optimal quality and financial outcomes. This individual is a key member of the Quality and Compliance team and advocates for patient healthcare needs by coordinating care to minimize the fragmentation of the healthcare delivery systems.

Primary Job Responsibilities:

  • Coordinate and oversee all direct and indirect patient services provided by care navigators
  • Be responsible for the oversite of the assessment and evaluation, intervention, and documentation of patient and family needs
  • Oversee and monitor the high-risk registry and assignment of patients
  • Provide leadership to the team promoting consistent performance improvement, teamwork, and leading by example
  • Monitor that all patients are screened for common social determinants of health (SDOH) and protocol for intervention and/or referral is completed based on results of screen
  • Develop and maintain a community based resource list as well as develop and enhance relationships with these resources
  • Collaborate with providers and practice staff in identifying appropriate patients for care management utilizing established Care Management criteria.
  • Collect regular and pertinent data about the health status of the patient; compile patient data and prepare outcome analysis
  • Formulate and implement an action-oriented care management plan that addresses the patient’s identified needs, taking into consideration family needs or concerns, potential issues, and care goals; identify and education patient and family of available resources
  • Initiate care conferences to discuss multidisciplinary team responsibilities, patient progress, recommendations and concerns
  • Perform follow-up calls for patients recently discharged from acute hospitalizations and who are high risk for readmission
  • Determine and complete appropriate referrals; serve as a liaison to providers, patients and families for the coordination of services
  • Maintain accurate and timely documentation with EMR and other healthcare databases
  • Service as a patient and family advocate giving priority to customer service issues and promoting positive interpersonal relationships among patients, providers, and the community
  • Assist patient with overcoming barriers with attending scheduled appointments


Education, Certification, and Experience Requirements

  • Registered Nurse with Bachelor’s degree or a Master’s prepared licensed Social Worker
  • Licensed Social Worker with experience working in medical setting
  • Active and current licensure by the AZ State Board of Nursing, or, active and current Licensed Clinical Social Worker (LCSW) or Licensed Masters Social Worker (LMSW) by the AZ State Board of Behavioral Health Examiners
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