Clinical Case Manager - Excel Medical Center

Striving for a Healthier Community!

Excel Medical Center is seeking an experienced medical Case Manager to join us in our mission to provide primary care adult medicine to the underserved community in Philadelphia!

Be a part of meaningful work by providing support to patients seeking quality healthcare.

Excellent opportunity to have a positive impact on our patient's health while working directly with patients, Providers, insurer's and the patient's clinical staff.

Who are we?...

Excel Medical Center LLC is a growing primary care practice with a mission to serve the medically-underserved adult, urban population located in the Philadelphia area via our 15 primary care clinical locations.

In addition, we provide medical management in 13 Nursing Homes/Long-Term Care (LTC) setting.

Join a mission-driven, growth-oriented urban-based healthcare practice that really cares about the community!

We are looking for a talented Case Manager to enhance the quality of patient management, maximize patient care and promote overall cost-effectiveness.

Case Manager will be accountable for most of the full patient care cycle, such as setting up clinical appointments, connecting to community resources, following up after hospital post-discharges and clinical appointments, and ensuring that any SDOH needs are addressed.

Case Manager duties include assessing, planning, implementing, monitoring, and evaluating actions required to meet the client's health and human services needs.

Role and Responsibilities

• Assist patients through the healthcare system by acting as a patient advocate and navigator.
• Participate in quality improvement initiatives (HEDIS, Value-based care, PCMH).
• Identify Care Gaps and coordinate patient services to close gaps.
• Coordinate continuity of patient care with external healthcare organizations and facilities, including hospital admission and discharge and referrals from the primary care provider to a specialty care provider.
• Coordinate continuity of patient care with patients and families following hospital admission, discharge, and ER visits. (Transition of Care Visits)
• Co-Manages high-risk patient care, including managing patients with multiple comorbidities or high risk for readmission to a hospital setting, including a registry in collaboration with the CCM team.
• Reviews all positive SDOH screenings and provides available community-based resources and referrals to patients with identified needs.
• Shares clear timely communication via chart documentation and team huddles with the healthcare team regarding patient status and plan of care.
• Participates in data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Patient-Centered Medical Home initiatives.
• Contributes input and evaluation in clinical care processes, utilization of resources, and development of new clinical tools, forms, and procedures to support patient care.

Knowledge and Experience

• CMA or have an active LPN
• 1-2 years prior experience within your field; separately 1-2 years Case Management experience.
• Prior office experience are preferred, including experience maintaining and working with various EMRs (Athena is +)
• Prior experience reaching out to insurance companies to obtain patient data and patient resources.
• Prior interactive experience utilizing patient care plan in direct coordination with a medical Provider, (Physician or Nurse Practitioner). Prior experience with SDOHs is a real +!
• Prior mid-large case load responsibilities; Can handle a case load volume of ~300 patients/month.
• Ability to effectively communicate/educate the patient and also educate/ communicate to the patient's family / support team.
• Intermediate-level computer skills with creating and modifying documents using Microsoft products (e.g. Excel and Word);
• Highly Self-motivated; reliable; strong attention to detail
• Maintains confidentiality
• Experience using judgement and discretion to appropriately escalate to the Provider in a timely manner.
• Complies with all EMC's policies and procedures.
• Excellent interpersonal skills.
• Demonstrates excellent communication and customer service skills and functions as a positive team member.
• Ability to sit for long periods of time and use a pc keyboard.
• Able to deal with stress and conflict appropriately.

EMC is an EOE