Provide care management services out of the Shively Community Based Outpatient Clinic, and supports Veteran patients at risk for high utilization of healthcare resources and the discharge of patients in a timely manner. The Home Health Care Services (HHCS) Care Manager is responsible for continuity of care for patients in need of home and/or community based care for the following programs: Home Care Based Services (HCBS), H/HHA, HPC, Home Telehealth (HT), and Home Based Primary Care (HBPC). PAY SCHEDULE NF45 Duties will include assuming responsibility and accountability for patients requiring care management/coordination of care in any of the above areas. Manages the delivery of multiple labor-intensive services to target populations while providing assistance to patients at risk for high utilization of health care resources which includes assessing, educating, referring, coordinating, advocating, monitoring, and periodically reassessing health needs. Facilitates communication between the patient and the provider, and promotes prompt intervention based on close/frequent monitoring. Knowledgeable about resource availability and allocates service resources along a continuum of care to restore or maintain the patients independent functioning to the fullest extent possible. Demonstrates the application of broad based clinical and problem solving skills, attention to detail, and independence in practice. Collaborate with Discharge Planners, Physician teams, Social Workers, Home Health Agencies, Hospice Agencies and all other disciplines in the development and management of an interdisciplinary plan of care, assurance of continuity of care, quality of care, access to care and cost efficiency regardless of payer source. Selects appropriate VA and/or community services and programs to match patient care needs. Other duties as assigned. Work Schedule: Monday - Friday (8:00a-4:30p) Financial Disclosure Report: Not required
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.