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Category: Nursing Professionals
Facility: IHA Administration
Department: Care Team
Schedule: Full Time
Hours: 40 Hours
Job Details: Master's Degree
Licensed Master's Social Worker (LMSW)
3 - 5 years of experience required


This is a clinical leadership position that serves as an integral member of the office PCMH care team.  Provides care management and care coordination for adult and pediatric patients with mild to moderate illness, under minimal supervision.  In partnership with primary care practice leadership team, the Moderate Risk Care Manager leads population management within the team through process improvement workflow redesign, providing assistance with training, and delegating to other members of the team.

Collaborates with members of the health care team to empower patients to manage their chronic conditions; assists patients, who are at risk for developing chronic conditions, to minimize these risks; serves in an expanded health care role to collaborate with PCP and patients to ensure the delivery of quality, efficient, patient centered, and cost-effective healthcare services.  

Assesses, plans, implements, monitors, and evaluates delivery of individualized patient care with the goal of optimizing the patient's health status.  Provides self-management support and patient education; works primarily with moderate risk patients to optimize control of chronic conditions and prevent/minimize long term complications.  Manages a caseload of approximately 500 patients; of which 90-100 are actively supported at a time.




1.       Partners with office leadership: PM, SMD, CC to identify and develop improvement strategies that support quality initiatives.

2.       Is an active member of the office-based care team.  Works closely with office care teams to help them identify and refer eligible patients for care management support.  Accepts referrals from providers and clinical staff and works as a member of the practice team in patient care as appropriate to support the prevention and/or care management.

3.       Identifies common populations/high volume complex populations within the practice and prioritizes and directs interventions.   Clinical work entails:

a.    Coordinates and provides patient education for common patient populations within the office. 

b.    Develops/recommends patient education materials for utilization across key populations that are seen in the practice in collaboration with the PO.

c.     Actively utilizes and teaches the tools necessary for population management:  ex: registry utilization.

d.     Designs individual plan of care for low-moderate level CM based on evidence-based guidelines.  Fosters a team approach by collaborating/referring high risk/complex patients to supporting members of the care team (Complex CM, RD, CDE, pharm, panel manager, etc.) and ensures coordination of services.

e.     Assesses health behavior and disease-specific risks; identifies a plan of action for patients.  Assures clinical compliance with follow through utilizing reminders, follow-up calls, and patient and office education.

f.      Refers selected patients to determined community resources and coordinates with these resources.

g.     Provides patient-specific feedback to providers and clinical team.

h.     Provide face-to-face and telephone counseling and referral for common office populations. Counseling will include health behavior change and chronic disease management. 

i.      Leads and participates in disease specific disease management evidence-based care initiatives.

j.      Provides regular feedback on patient progress to referring clinicians.

k.     Utilizes relevant computer information support including the EMR and any other care management and/or clinical IS systems needed to complete the tasks of clinical care and performance reporting.

4.     Participates in quality improvement and performance review efforts to identify practice specific goals for designated patient groups.

5.       Evaluates and manages day to day workflow and adjust as needed to increase efficiencies.

6.       Performs other duties as assigned and works within scope of certification/licensure.




1.    Creates a positive, professional, service-oriented work environment for staff, patients and family members by supporting the IHA CARES mission and core values statement.

2.    Must be able to work effectively as a member of the interdisciplinary Care Management team.

3.    Successfully completes IHA's "The Customer" training and adheres to IHA's standard of promptly providing a high level of service and respect to internal or external customers.

4.    Maintains knowledge of and complies with IHA standards, policies and procedures, including IHA's Employee Handbook.

5.    Maintains complete knowledge of office services and in the use of all relevant office equipment, computer, and manual systems.

6.    Maintains strict patient and employee confidentiality in compliance with IHA and HIPAA guidelines.

7.    Serves as a role model, by demonstrating exceptional ability and willingness to take on new and additional responsibilities.  Embraces new ideas and respects cultural differences.

8.    Uses resources efficiently.

9.    If applicable, responsible for ongoing professional development – maintains appropriate licensure/certification and continuing education credentials, participates in available learning opportunities.




Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position.




EDUCATION:   Master of Social Work License. Completion of self-management support training preferred.

CREDENTIALS/LICENSURE:  Licensed's Masters of Social Work. Valid CPR certification.

MINIMUM EXPERIENCE:   Three to five years of experience within the past five years with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting. Care management experience and experience as participant in continuous quality improvement preferred.




1.     Ability to effectively support department leadership with the care management team, providing feedback and guidance to staff and demonstrating effective conflict resolution.  Ability to affect change.

2.    Knowledge of patient care management procedures and policies related to position responsibilities. Working knowledge of quality improvement.

3.    Works autonomously. Possesses critical thinking skills and ability to analyze complex data sets. Ability to manage complex clinical issues utilizing assessment and triage skills and protocols. Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment and patient education.

4.    Understands chronic disease management strategies and is able to implement appropriate evidence-based interventions, protocols and guidelines. 

5.       Maintains the ability to utilize guidelines and standards of care for management of chronic diseases.

6.       Ability to make "cold calls" and engage patients into the program effectively.

7.    Proficient/knowledgeable in medical terminology.

8.    Proficient in operating a standard desktop and Windows-based computer system, including but not limited to, electronic medical records, email, e-learning, intranet, Microsoft Word and Excel,  and computer navigation.  Ability to use other software, such as NextGen Care Management Template, as required while performing the essential functions of the job.

9.    Excellent communication skills in both written and verbal forms, including proper phone etiquette.  Ability to speak before groups of people and display positive listening, and relationship-building and critical analysis skills. Demonstrated skills with influencing and negotiating individual and group decision-making.

10.  Ability to work effectively with various levels of organizational members and diverse populations including IHA staff, providers, practitioners, patients, family members, insurance carriers, vendors, external customers and community groups.

11.  Good organizational and time management skills to effectively juggle multiple priorities and time constraints.

12.  Ability to exercise sound judgement and problem-solving skills, specifically as it relates to resolving care management issues.

13.  Ability to coordinate, plan, evaluate and integrate clinical education and professional development activities that foster and maintain care management best practices.

14.  Ability to handle patient and organizational information in a confidential manner.

15.  Knowledge of the compliance aspects of clinical care and patient privacy and best practices in medical office operations.

16.  Ability to work flexible schedules.

17.  Ability to travel to other office/practice sites and meeting and training locations.

18.  Successful completion of IHA competency-based program within introductory and training period.




1.     Physical activity that often requires keyboarding, phone work and charting.

2.     Physical activity that often requires extensive time working on a computer.

3.     Physical activity that often requires handling and lifting patients walking, standing, bending, stooping, reaching, climbing, kneeling and/or twisting.       

4.     Physical activity that may require lifting, pushing and/or pulling up to 20 pounds.

5.     Specific vision abilities required include close vision, depth perception, peripheral vision and the ability to adjust and focus. 

6.     Manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment.

7.     Must hear and speak well enough to conduct business over the telephone or face to face for long periods of time in English.




This job operates in a medical facility and requires regular walking to various locations around the hospital/clinic. Employees will be working where there is patient care equipment. Hazardous materials, including bloodborne pathogens and bodily fluids are also present. Exposure to sharps, x-rays, patients' conditions and some unpleasant sights, smells and contagious diseases is possible.  This position requires significant interaction with people (many of whom are scared, hurt and/or ill) which can be stressful and result in competing priorities.


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