Supervisor, Chronic Care Management

1. Demonstrates an understanding of care management, complex disease management, transitions of care , post-acute care options, and community management standards.
   1. 1. Outreaches to and enrolls patients in chronic care management programs, establishing a therapeutic relationship and managing the patient's engagement for the duration of the program

1 2. Educates the patient, family or caregivers, and members of the health care delivery team about treatment options, community resources, insurance benefits, and/or psychosocial concerns so that timely decisions can be made.

1 3. Facilitates communication and coordination between members of the healthcare team and the patient to minimize fragmentation in service.

1 4. Demonstrates the ability to evaluate care management data to identify trends, develop action plans, and program modification for improved patient outcomes.

1 5. Identifies changes in patient condition warranting interventions and refers appropriately.

1. Demonstrates an ability to serve as a collaborative member of a multidisciplinary healthcare team.
   1. 1. Leads interdisciplinary team rounds to address utilization/resources and progression of care issues. Assists in developing and implementing an improvement plan to address issues.

2 2. Leads the team in developing cooperative relationships with internal and external partners or departments to provide exemplary service and achieve goals.

2 3. Maintains objectivity in decision-making and utilizes facts to support decisions.

2 4. Assists in eliminating barriers to achieve integrated, efficient, and quality service.

2 5. Utilizes resources efficiently and effectively.

1. Demonstrates an understanding of clinical standards, quality performance goals, and expected outcomes.

   3. 1. Demonstrates application of evidence-based practice and clinical practice guidelines to care plans and patient interventions.

   3 2. Develops knowledge of population health, health equity, value-based care concepts and their application to the goals and objectives of the role and the department.

   3 3. Demonstrates an understanding of managed care trends, payer regulations, reimbursement, and the effect of utilization on the different methods of reimbursement.

   3 4. Facilitates continuing education to develop new knowledge and skills applicable to the role and function.

   1. Performs other duties as required or requested.
   2. Provide leadership and supervision of the multidisciplinary chronic care management team. Provides oversight of group functioning, assignments and provides supervision to staff in day to day assignments.
   3. Provides organization and support to the orientation of new staff, incorporation into the organization and the department as a whole and provides leadership and direction as needed to all members
   4. Brings issues forward that are central to the role and contributes to the improvement and ongoing development of core critical processes
   5. Continually identifies new opportunities to promote professional development and success as an interdisciplinary member of Yale New Haven Health staff, bridging throughout the continuum for the quality care of all patients.
   6. Provides daily supervision while maintaining a case load within the chronic care management team.
   7. Meets with Leadership to develop goals to consistently advance and support the philosophy and goals of YNHHS Amb Care Management Department and the health system.
   8. Sets example for accountability and responsibility of all daily activities and hold others accountable for the same. Takes opportunities to demonstrate visionary thinking, and supports others to do the same.

EDUCATION (number of years and type required to perform the position duties):

Minimum of a Baccalaureate degree in clinically related field. Advanced degrees preferred. CT R.N. license required.

EXPERIENCE (number of years and type required to meet an acceptable level of performance):

Minimum of 5 years of combined clinical experience in direct patient care and care coordination/case management in an acute, community, or post-acute provider or health plan. Experience in chronic care management preferred.

SPECIAL SKILLS:

Motivational interviewing skills necessary.

Excellent verbal and written communication skills.

Excellent organizational skills and ability to handle multiple priorities.

Ability to work in an independent role with minimal supervision.

Functions as an integral team member and demonstrates flexibility in sharing responsibilities.

Validated translation capability preferred.

Working knowledge of computers and basic software applications used in job functions, such as word processing , databases, spreadsheets, and others as needed.

ACCOUNTABILITY (how this position is held accountable for such as goals achievement, budget adherence, or other areas of accountability):

Adheres to and upholds team to communicated care management productivity metrics, including caseload , engagement volume, and time to closure. Adheres to quality standards for care management per policy, including appropriate cases opened, comprehensive documentation, actionable care plans, multidisciplinary care team referrals, and appropriate cases closed in a timely fashion.

In personal and job-related decisions and actions, consistently demonstrates the values of integrity (doing the right thing), patient-centered (putting patients and families first), respect (valuing all people and embracing all differences), accountability (being responsible and taking action), and compassion (being empathetic).

In personal and job-related decisions and actions, consistently demonstrates the values of integrity (doing the right thing), patient-centered (putting patients and families first), respect (valuing all people and embracing all differences), accountability (being responsible and taking action), and compassion (being empathetic).

COMPLEXITY (describe planning, problem solving, decision making, creative activity, or other special factors inherent in the responsibilities of this position):

Requires independent problem-solving skills in coordinating care across the continuum and within the health care system. Must embody principles of High Reliability including communicating effectively with peers and arcing up concerns, accountability, mentorship and practicing and accepting a questioning attitude, maintaining HIPPA regulations.

LICENSURE/CERTIFICATION:

RN Licensure in Connecticut required; Certified Case Manager (CCM) or accredited equivalent certification preferred.

SPECIAL WORKING CONDITIONS AND PHYSICAL DEMAND:

Role is primarily a remote work position with an onsite expectation (primary care clinics or trainings) at min weekly.

Ability to attend initial onsite orientation and onboarding program as well as monthly onsite training obligations . Adheres to all organizational remote worksite standards.

Rotating on-site time in ambulatory sites required, on-site training with teams, prefer strong knowledge of Chronic Care Management

The Supervisor of Ambulatory Chronic Care Manager (RN) is as a member of the enterprise Ambulatory Care Management team and is accountable for overseeing the team improving the health outcomes for all patients, with a particular focus on patients in value-based/risk contracts. The Ambulatory Chronic Care Manager Supervisor oversees a multi-disciplinary team under the direction of the Ambulatory Care Management leadership. The working supervisor is responsible for ensuring nursing assessments, evaluations, screenings, and development of action plans to mediate gaps in clinical care are performed in alignment with program goals. The role will participate in and oversee all components of care management including, but not limited to, management of care transitions , medication reconciliation/review, provide patient-centered education related to acute or chronic illnesses, evaluate for social determinants and barriers that impact care management, adhere to quality metrics, facilitate communication among providers, and advocate for the patient, family, and support system.

EEO/AA/Disability/Veteran.