**Description** Position purpose: Provides longitudinal care management services for identified high risk and/orc complex Emory patients. Utilizes clinical expertise to perform care management screening, assessment/evaluation, develop and implement a patient centered plan of care with shared goals, and appropriate interventions. Provides extraordinary and value-based care management. Collaboratively with patients, family, caregivers, significant others, healthcare providers, payers, community-based providers, and other involved parties to provide effective, efficient, impatient centered care management services. Scope: We are seeking a dedicated and compassionate Care Manager to join our team, specializing in the management of high-risk and complex patients across the continuum of care. The Care Manager will play a pivotal role in coordinating care, addressing medical and social determinants of health, and ensuring seamless transitions between care settings. This position does not involve the direct provision of clinical care but instead focuses on patient advocacy, resource coordination, and collaboration with multidisciplinary teams. Provides care management to a defined patient population in accordance with Emory¿s healthcare policies, procedures, guidelines, and professional licensure. Essential Job Duties: - Conduct comprehensive assessments to evaluate medical, psychosocial, and environmental needs. - Understand, practices, and promotes the philosophy and guiding principles of integrated care management. Develops relationships and collaborates with case/care management staff in other healthcare settings and across the continuum of care. - Meets with a patient in a timely manner and conducts an initial care management assessment/evaluation. - Develops a patient centered plan of care, involving the patient/family caregiver/significant others in the process. Problems and strengths are defined; shared goals, and desired outcomes are established. - Collaborates, educates, communicates, and networks with healthcare providers across the continuum to ensure the patient¿s care planning needs are met. - Advocates on behalf of patient, communicating and collaborating with healthcare providers, payers, physicians, and community-based services, where appropriate, to establish an appropriate and integrated care plan for each patient. - Provides patient/caregiver self-management, education, referrals, and support. - Promotes mental health integration by collaboration with mental health/behavioral health providers. - Facilitates transitions of care from one healthcare setting to another. Actively participates in system and regional process improvement initiatives to improve transitions of care. - Identifies and assists patient/members with palliative care and end of life care planning needs. - Evaluates the effectiveness of the patient¿s plan of care and outcomes and modifies the plan of care or specific interventions, as appropriate. - Functions as a team leader, ensuring effective day-to-day operations and problem-solving, for the community case management team. Promptly escalates concerns to the appropriate chain of command. - Effectively and efficiently leads, interdisciplinary care, conferences, using collaborative practice, models that promote interdisciplinary care planning and teamwork. - Completes timely and accurate documentation in the medical record using knowledge of documentation standards for the department to facilitate communication with team members. Documentation is done in compliance with all clinical guidelines and billing/reimbursement standards. - Organizes and prioritizes daily work by assessing new, current, and discharging. Patient needs an area(s) of responsibility. - Ensure that productivity standards and expectations are met. Minimum requirements: - Bachelor's degree in nursing (BSN) from an accredited institution (degree will be verified) or licensed social worker with Master¿s degree from an accredited institution - Current RN or LCSW license in state of practice. - Current driver's license in state of practice. - Three years of clinical nursing experience or medical social work - Three years of experience working as a case/care manager in a healthcare setting. - Basic computer skills and knowledge of word processing software. - As a safe driver will be asked to provide a copy of their motor vehicle record (MVR) from the department of motor vehicles upon hire. - Auto liability insurance with at least the states required minimum limits (at least $100,000/$300,000 is encouraged) - Ability to work independently, be self-motivated, have a positive attitude, and be flexible in a rapidly changing healthcare environment. Preferred qualifications: - Case management certification. - Team leader or manager experience. - Knowledge of community-based health services and resources. Physical requirements: - Ongoing need for employee to see and read information, labels, assess patient needs, operate, monitor, and identify equipment and supplies. - Frequent interactions with patient care, providers, patients, and visitors that require employee to verbally communicate, as well as here and understand, spoken information, alarms, needs, and issues quickly, and accurately, particularly during emergency situations. - Need to walk and assist with distributing supplies and equipment. This includes pushing/pulling portable equipment, including heavy items. Of required to navigate crowded and busy rooms (full of furniture, equipment, power cords on the floor, etc.). Need to ascend and descend uneven surfaces to assess patients. - Expected to drive a vehicle which requires sitting, seen and reading signs, traffic signals, and other vehicles. **Additional Details** Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law. Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. To request this document in an alternate format or to request a reasonable accommodation, please contact Emory Healthcare’s Human Resources at careers@emoryhealthcare.org . Please note that one week's advance notice is preferred. **Connect With Us!** Connect with us for general consideration! **Division** _Emory Decatur Hospital_ **Campus Location** _Decatur, GA, 30033_ **Campus Location** _US-GA-Decatur_ **Department** _DEC-Care Management_ **Job Type** _Regular Full-Time_ **Job Number** _144081_ **Job Category** _Clinical & Nursing Support_ **Schedule** _8a-4:30p_ **Standard Hours** _40 Hours_ **Hourly Minimum** _USD $44.00/Hr._ **Hourly Midpoint** _USD $50.60/Hr._ Emory Healthcare is an Equal Employment Opportunity employer committed to providing equal opportunity in all of its employment practices and decisions. Emory Healthcare prohibits discrimination, harassment, and retaliation in employment based on race, color, religion, national origin, sex, sexual orientation, gender identity or expression, pregnancy, age (40 and over), disability, citizenship, genetic information, service in the uniformed services, veteran status or any other classification protected by applicable federal, state, or local law.