Community Health Systems Care Manager - RN/LPN - 1.0 FTE - Physicians Health Alliance in Scranton, Pennsylvania


  1. Provide proactive outreach including telephonic and face-to-face encounters in the home or clinical setting.

  2. Identify patients in need of disease management intervention

  3. Prioritize patient follow-up based on care management assessment and risk stratification.

  4. Complete a structured assessment of medical, biopsychosocial support and self-management support needs.

  5. Work collaboratively with the primary care provider and other practice staff to develop an individualized plan of care that identifies goals and targeted interventions for all patients in care management.

  6. Provide transition of care management and act as liaison to hospital, long-term care, specialty, home health services and other community-based services for high-risk care managed patients.

  7. Maintain ongoing appropriate documentation on care coordination to promote Practice team awareness and ensure patient safety and follow through on care plan.

  8. Assist patients in problem solving potential issues related to the patient s health care system, financial and psychological barriers.

  9. Function as the navigator and point-of-contact for high-risk patients and family, with the patient and family having direct access for asking questions and raising concerns.

  10. Ensure open communication regarding patient interactions with physicians and office staff.

  11. Help patients with problems in arranging referrals, screenings, and test procedures.

  12. Screen and refer as appropriate for depression and other psychological treatments.

  13. Assume an advocate role on patient s behalf with the carrier to coordinate benefit management for appropriate supplies and services for the patient in a timely fashion.

  14. Identify and utilize cultural and community resources; establish and maintain relationships with identified service providers.

  15. Coordinates care with external disease management or case management organizations.

  16. Provide medication management, including medication reconciliation and making recommendations to primary care for medication changes based on evidence-based protocols.

  17. Collaborate with primary care to establish and update a shared care plan.

  18. Provide support for improving health behaviors and self-management skills: Goal Setting, Action Planning and Problem Solving.

  19. Provide more intensive follow-up during care transitions and other high-risk periods.

  20. Provide information and education regarding screenings and test results.

  21. Care Managers play an important role in supporting quality improvement for chronic care, such as participating in and supporting planned and group visits, and development of new forms and procedures.

  22. Care Managers play a key role in providing clinical and self-management support training to non-RN and other practice staff as needed.



3-5 years experience in clinical nursing, care management and knowledge of the basic concepts and principles of chronic care disease management preferred.

Job: Nursing

Organization: Physicians Health Alliance

Location: PA-Scranton

Requisition ID: 1834685