MSSP Clinical Case Manager (MA/LPN/RN)

Description

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 MA, LPN, or RN for the primarily remote MSSP Clinical Case Manager position. The ideal candidate will have excellent communication and interpersonal skills, a solid clinical background, and experience working with MSSP. 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!

IHC’s robust benefits and compensation package includes:

• $2000.00 retention bonus paid after one year
• No nights or weekends
• Generous Paid Time Off and Floating Holidays
• Day 1 Insurance benefits eligibility
• 403(b) Retirement Plan matching at one year of employment
• Employer-paid Group Life, Short-term disability, and Long-term disability coverages and HSA employer contributions
• Flexible Leave of Absence programs
• Personify Health Wellness program with paid incentives for participation
• Employee Assistance Programs with 24/7 access to therapy consultation services

MSSP Clinical Case Manager Job Overview:

The MSSP Clinical Case Manager facilitates communication between patients, their families, caregivers, providers, and other healthcare team members. 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 Case Manager is integral to the Patient-Centered Medical Home and Patient Care Team.

Operations functions:

• Perform social determinant of health (SDoH) assessments and link patients with appropriate resources
• Provide general care coordination orientation to patients and communicate the goals/objectives of the program
• Assist patients referred to/from providers, care managers, and other points of entry
• 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
• Compile and distribute educational material per patient need
• 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 that 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 of patient interactions in the care management system.
• Provide disease-specific and preventive care patient education
• Executes effective interventions to reduce inappropriate ER visits or length of hospital to improve care and reduce costs

Quality and administrative functions:

• Assist in the collection and assembly of quality improvement information to track and trend
• 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
• Compile and distribute educational material based on patient need
• Perform follow-up activities with patients as needed after emergency department visits
• 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

Requirements

• Current Medical Assistant, Licensed Practical Nurse, or Registered Nurse licensed in the state of Indiana.
• 2 years general experience providing patient care in community or hospital setting.
• 1 year case management experience or experience providing health education and outreach activities.
• Care coordinator certification preferred.
• Bilingual preferred but not required.
• Occasional travel is required to participate in offsite IHC meetings.
• Must reside in Indiana.

Equal Opportunity Employment Statement

We are an equal opportunity employer. All applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.