Clinical Care Manager

Indiana Health Centers, Inc. (IHC) is a mission-driven organization providing high-quality, affordable healthcare to underserved and uninsured populations since 1977. At IHC, a Federally Qualified Health Center, we specialize in integrated care which means having access to essential services to meet the needs of patients we serve in the community. With ten healthcare centers, eight Women, Infants, and Children (WIC) nutrition program locations, a Mobile Health Unit, and in-house Pharmacy services, we offer primary medical, dental, and behavioral healthcare services to community-based patient populations throughout Indiana that are diverse in age, educational background, and income level.

IHC seeks an experienced LPN or RN for the Clinical Care Manager position. The ideal candidate will have excellent communication and interpersonal skills, experience working with patients with complex chronic disease states and multiple comorbidities, and ability and patience to navigate complex systems of care. They should also be organized, detail-oriented, and able to work independently. If you meet these qualifications, we encourage you to apply for this exciting opportunity! Clinical Care Manager Job Overview: The Clinical Care Manager facilitates communication between patients, their families, caregivers, providers, and other members of the healthcare team. Their focus is to offer individualized assistance to patients with complex disease states and multiple comorbidities, as well as their families and caregivers, to overcome healthcare system and community barriers and facilitate consistent and timely medical care across the continuum of care. The Clinical Care Manager is an integral part of the Patient-Centered Medical Home and Patient Care Team.

Perform social determinant of health (SDoH) assessments. Link patient with resources based on SDoH assessment. Provide general clinical care coordination orientation to patients and communicate the goals and objectives of the program. Provide assistance for patients referred to/from providers, case managers, and from other points of entry. Evaluate patients deemed high risk by risk algorithm for care management and enroll patients who elect to participate. Guide patients through transitions of care from inpatient settings to home. Contact patients to facilitate continuity of care and escalate issues to appropriate team members. Assist patients with adherence to existing self-management goals or development of new goals (in collaboration with practice clinical staff). Assist in identifying individual and/or community needs which encourage healthy lifestyles and environments (i.e., community resources, transportation assistance, exercise programs, etc.). Interact with the multidisciplinary team on behalf of the patient to resolve barriers. Communicate outcomes to patient/family/caregivers. Maintain timely and appropriate documentation on patient interactions in the care management system. Provide disease-specific and preventive care patient education per patient need. Execute effective interventions to reduce inappropriate ER visits or length of hospital to improve care and reduce costs. Quality functions: Assist in the collection and assembly of quality improvement information for the purpose of tracking and trending. Participate in cross-functional team meetings aimed at improving patient outcomes or operational processes. Regularly participate in care team huddles with care managers to identify priorities, tasks, and interventions. Perform population management activities as assigned. Administrative functions: Compile and distribute educational material based on patient need. Perform follow-up activities with patients as needed after emergency department visits or inpatient discharges. Assist with scheduling medical and specialty appointments. Provide reminder phone calls for appointments and/or follow-up calls post appointment. Retrieve discharge summaries and copies of medical records. Other: Develop and maintain excellent working knowledge of common chronic conditions and seek information as part of continuous learning.