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How Youll Help Transform Healthcare:

The Care Connection Case Manager provides care management for specific patient populations utilizing clinical expertise communication and problem-solving skills to achieve optimal clinical and resource outcomes. Promotes cost-effective care by minimizing fragmentation maximizing coordination and facilitating patient/family movement through the system. Applies protocols when appropriate and facilitates referrals providing linkages to health and wellness resources across the health care continuum. Promotes interdisciplinary collaboration and teamwork to progress the plan of care. Must possess knowledge of growth and development appropriate to age group served and incorporate plan to meet needs into plan of care.

• Performs patient/family data collection to assist in identifying individualized care management needs
• Works with all Care Coordinators to identify individual care management needs with Care Team to help identify those patients who need close follow up resources additional education and support.
• Coordinates plan of care and services directing liaison activities to appropriately integrate the patient into the health care continuum.
• Facilitates continuity of care using multidisciplinary collaboration and coordination of appropriate health care services and community resources across the care continuum.
• Maintains effective communications with all disciplines.
• Coordinates and manages all care transitions with a focus on comprehensive accurate and effective communication.
• Engages and empower patient/ caregiver as an active participant in disease/ condition management.
• Determines readiness/ willingness to change based on protocols and partners with patient/ caregiver/ care team in identifying goals plan of action.
• Identifies and tracks patient/ caregiver capacity for and confidence in self-care.
• Supports patient/ caregiver in adopting healthy behaviors and promotes lifestyle changes.
• Advocates for the patient and family throughout the entire episode of care.
• Participates in Advisory Committee with medical consultant Educational Consultant Director and parents to review processes improvements and educational needs for children with special needs.
• Actively participates in quality improvement projects for our center.
• Develop and maintain center policies and procedures that adhere to polices for care coordinators related to performance measures and industry standards.
• Analyze centers data regarding level of care caseloads outcomes etc. to identify trends establish benchmarks and along with program development and planning.
• Implement quality improvement activities to ensure quality based on national case management standards.

Must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development through the life span possess the ability to assess data reflective of the patients status interpret the appropriate information needed to identify each patients requirements relative to his or her age and specific needs and provide the care needed as described in departmental policies and procedures. Must follow mandated regulations and policies. Works with minimal supervision. Must have excellent communication skills both verbal and written to address individuals of varying educational levels. Critical thinking and organization skills are important. Normal office environment with some potential travel to other facilities.

What We Require:

Education: Graduation from an accredited school of nursing bachelors degree preferred. Or bachelors degree in social work or related degree required.

Experience: RN experience in a physician practice or clinic preferred Or social work experience in health care setting preferred.

Licensure/Certifications/Registration: Current RN license for the state of VA required or LCSW preferred.

Life Support: AHA BLS-HCP required in practices where the Care Coordinator provides direct patient care.

Other Minimum Qualifications: Must demonstrate knowledge and competency in the following areas: positive interpersonal oral communication skills; effective written communication skills; analytic skills; team player; courteous; ability to resolve complaints/problems; customer-focused philosophy of service delivery; ability; willingness to work as an integral member of a multi-skilled team. Also demonstrate knowledge and competency in computer literacy; community and system resources; effective interpersonal relations; analysis and research methods.

This job description is only meant to be a representative summary of the major responsibilities and accountabilities performed by the incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

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For more information contact the HR Service Center at 1-.

Carilion Clinic is an Equal Opportunity Employer: We provide equal employment opportunities to all employees and applicants without regard to race color religion sex national origin age (40 or older) disability genetic information or veterans status. Carilion is a Drug-Free Workplace. For more information or for individuals with disabilities needing special assistance with our online application process contact Carilion HR Service Center at 8:00 a.m. to 4:30 p.m. Monday through Friday.

For more information on E-Verify: Pay and Well-beingat Carilion Clinic

Carilion understands the importance of prioritizing your well-being to help you develop and thrive. Thats why we offer a well-rounded benefits package and many perks and well-being resources to help you live a happy healthy life at work and when youre away.

When you make your tomorrow with us well enhance your potential to realize the best in are benefits available to you when you join Carilion:

• Comprehensive Medical Dental & Vision Benefits
• Employer Funded Pension Plan vested after five years (Voluntary 403B)
• Paid Time Off (accrued from day one)
• Onsite fitness studios and discounts to our Carilion Wellness centers
• Access to our health and wellness app Virgin Pulse
• Discounts on childcare
• Continued education and training