Clinical Care Manager

Department: Penn Partners in Care 2

The Clinical Care Manager is responsible for promoting organizational values of patient and visitor satisfaction by demonstrating

courtesy and respect for families, visitors and other employees. Collaborates with practices and actively provides clinical

support to "high-risk" patient populations for multiple practices - in all age groups ranging from young adulthood through

geriatrics. Demonstrates competence in the assessment, treatment and care of patients serviced. Will include

travel, telephone or telehealth encounters as appropriate to patient needs.

• Designs and implements care management support activities for high risk patients with chronic diseases and high medical

service utilization.

• Collaborates with physician and practice staff in identifying appropriate patients for care management utilizing established

criteria. Collaborates with the patient and provider to establish and implement a care management plan using evidencebased

guidelines. Develops patient objectives and measures progress according to standards of care.

• Triages patient telephone calls and provides consultation regarding ongoing symptom management resulting from treatment

and disease, analysis of intervention regarding diagnostic work-up, assessing and managing acute emergencies, managing

family concerns as needed, liaison activities with affiliated physicians, nurses, pharmacists and emergency rooms.

• Initiates appropriate evaluation and management of emergency situations.

• Coordinates patient’s management/treatment plan throughout the institution.

• Instructs patient/family regarding medications and treatments. Educates patients regarding health and illness prevention.

Recommends community resources to meet patient and family needs. Develops patient education programs.

• Creates, uses, and maintains patient-specific care management tracking system that identifies/ reports on patients who

will benefit from care management services, the subsequent patient progress, and associated interventions.

• Supports QA and maintenance efforts for patient registries and quality reporting. Works with the Clinical Analyst to

summarize and analyze data from registries

• Promotes patient self-management and empowers patient and families to achieve optimal health outcomes. Assists patient

to identify and/ or develop and utilize their support systems.

• Evaluates the effectiveness of care management plan in meeting established care goals and revises the plan as needed to

reflect changing needs, issues and goals.

• Prepares and maintains appropriate documentation as required.

• Collaborates with all members of the health care team to resolve patient health, social or behavioral health needs.

• Provides monitoring and continuity of care between physician visits. Maintains and reviews patient records, charts and

other pertinent information.

• Performs duties in accordance with Penn Medicine and entity values, policies, and procedures

• Other duties as assigned to support the unit, department, entity, and health system organization

Active PA or NJ RN license based on position location. Dual (NJ & PA) RN licensure required within 3 months of Hire required

We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.