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Mobile Transitions of Care (TOC) Care Manager

Company: Medical Home Network
Location: Chicago
Posted on: September 23, 2019

Job Description:

Medical Home Network is a not-for-profit healthcare innovations organization dedicated to improving access and disparity issues in the safety net through collaboration, technology and an integrated, team-based model of care. MHN has been a trailblazer in the journey towards patient-centered care model transformation that promotes coordination across the entire continuum and empowers care teams to deliver on what patients truly need.
Learn more about how MHN is disrupting healthcare at
Medical Home Network is staffed by a team of smart, motivated and results-oriented professionals. We are team players who value collaboration, peer feedback, and a can-do attitude. We come from a variety of backgrounds, but have one thing in common - the mission to improve health outcomes for vulnerable populations.
As a rapidly growing non-profit, MHN offers ample opportunities for advancement. We pride ourselves on the work we do-and are not just looking to make good hires, but great hires. Located in a vibrant downtown Chicago setting we are currently seeking a full-time Mobile Transitions of Care (TOC) Care Manager, to fill a role added due to organizational growth. This is an opportunity to be part of a unique and exciting organization.
JOB SUMMARYThe Mobile Transitions of Care (TOC) Care Manager provides care management on behalf of the ACO's medical homes. This is a clinical position and licensure is required. Mobile TOC Care Managers visit patients at acute and specialty care hospitals to ensure safe transitions of care inpatient to ongoing care in the medical home setting. The Care Manager will work collaboratively with the staff at hospital sites and at medical homes to facilitate better health outcomes and reduce readmission for patients. Essential FunctionsEngage with patients during hospitalization focusing on: reasons for hospitalization, reinforcing care management plan of care, updating information for the Medical Home Care Management team, plan of care post-discharge, and goal setting.Complete assessments as appropriate, such as the Health Risk Assessments, initiate Care Plan, TOC Bundle, and others as needed.Educate and support patients in health literacy, medication management, plan for follow-up and ongoing care, signs and symptoms of worsening conditions, functional or social needs, home and community-based services, advance directives, and other issues as identified.Interface with hospital care team including nurses, social workers, case managers, hospitalists, and other staff responsible for utilization management and discharge planning. Engage with other stakeholders such as the patients' family support network and external organizations the patient accesses for collaboration on patient success post-discharge.Assess patient readiness for change and work with care team to ensure patients discharges to proper services, specifically for mental health and substance use treatment. Identify and address barriers to assure an efficient and complete transitions of care.Participate in care team meetings and Integrated Care Team collaboration as necessary.Develop relationships with staff in inpatient hospitals (general acute and behavioral health) and Medical Home Care Management staff. Gather and share patients medical home information with the hospital care team; Gather and share information about the hospital stay to the medical home, including discharge planning documents.Work with the patient and medical home to secure timely follow-up appointments.Communicate and document activities and outcomes to the patient's medical home care manager regularly.Assist in leading transitions of care trainings for care management staff, focusing on patients hospitalized for behavioral health.Participate in quality improvement initiative as identified. CompetenciesMinimum of 3-5 years of recent work in care management, safety net/public health hospitals, FQHCs, academic medical centers, ambulatory care, physicians' group, professional practice, and/or experience working in Community Mental Health Centers, Substance Use Treatment settings, outpatient mental health services; or combination thereof.Excellent oral, written, and interpersonal communication skills.Ability to work independently and as part of a team with a wide range of individuals from a variety of care delivery sites and community agencies.Knowledge of and experience with systems used to improve population health and management of disease states such as diabetes, heart failure, COPD/asthma, mental health, and substance use.Excellent organizational skills and ability to be self-drivenKnowledge and experience with electronic information systems.Experience in program development and training/education.Proficient computer skills Required EducationBachelor of Science in Nursing RNMaster's Degree in Social Work LSW/LCSW Additional Eligibility QualificationsCurrent State of Illinois licensure for clinical social worker (LSW/LCSW) or Registered Nurse (RN) REQUIREDNurse Case Management Credentialing (RN-BC) or Certified Case Manager (CCM) preferredCertified Alcohol and Other Drug Counselor (CADC) preferredDemonstrated knowledge and experience in engaging and facilitating care for patients with complex needs related to behavioral health and multiple social factors affecting health outcomes.Care management or case management experience preferredKnowledge and experience working with Medicaid and Medicare populations preferredValid Illinois Driver's License and access to an automobileBilingual in Spanish preferred

Keywords: Medical Home Network, Berwyn , Mobile Transitions of Care (TOC) Care Manager, IT / Software / Systems , Chicago, Illinois

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