Manager, Care Delivery - Longitudinal

Description

Job Title: Manager, Care Delivery - Longitudinal
Status: Exempt
Reports To: Director of Care Delivery
Department: Care Delivery
Date: August 26, 2024
Location: Remote
 

About Us: Emcara Health is a leading provider of in-home assessments and longitudinal care, primarily serving a senior population. We are on a transformative journey to revolutionize in-home care and become the premier employer in the in-home healthcare industry. Our commitment to quality patient care, employee well-being, and innovation drives our mission.

Emcara core care teams are multi-disciplinary and include Community Health Workers (CHW), Registered Nurses (RN), Universal Providers including physicians, nurse practitioner, physician assistants, among other care coordination and specialized resources such as Clinical Pharmacists, Pharmacy Technicians, Social Workers (SW), Physical Therapists

Our care teams understand that vulnerable populations require a new brand of care to live their healthiest life possible- home-based advanced primary care. Advanced primary care is comprehensive, and includes medical, behavioral, and social care, and can be delivered either as the PCP of record, or in collaboration with patient PCPs to deliver an added layer of support.

Value-based payment methodologies allow our physicians and APPs both the time they need to restore the clinician-patient relationship, as well as ensure the patient and clinician are surrounded by a care team that is able to address all of their care needs, especially their behavioral and social needs.

Role Summary:

In partnership with the Market Medical Director, Director of Care Delivery, the Manager of Care Delivery is a Nurse Practitioner (NP), Physician’s Assistant (PA), or Registered Nurse (RN) who is responsible for providing clinical and operational oversight to a home-based medical practice that consists of multiple multi-disciplinary teams consisting of providers, field nurses, and community health workers.

While reporting to the Director of Care Delivery, the Manager of Care Delivery functions in a highly matrixed medical group where all markets are led by a dyad leadership team that includes a Market Medical Director. The Market Medical Director will provide clinical oversight and support with all Managers of Care Delivery and Providers within the market.

This individual will have demonstrated throughout their career an unparalleled dedication and success in achieving greater health equity for vulnerable populations. The Manager of Care Delivery will bring an unparalleled ability to act as a cross-functional leader, both through influence and collaboration to develop, advance, implement, and sustain enterprise-wide clinical strategy and goals. They will be responsible for executing this leadership in alignment with the GuideWell Equity Alliances focus on addressing systemic racism and the resulting health inequities it causes.

Ensuring our objectives are met will require both clinical and operational performance oversight, targeted interventions, and process improvement to create enduring performance in areas such as in outcomes improvement, care gap closure, high risk disease detection and management, and STAR measure attainment.

The Manager of Care Delivery must have a strong desire to continue delivering direct patient care while providing excellent leadership across critical functional areas. This role will spend at least 20% of their time dedicated to providing care to the most complex patients in our populations (high inpatient utilization, recently discharged, decompensated, etc.), both in person and virtually. In certain markets care will be delivered in group homes, assisted living and/or skilled nursing facilities.

Role Responsibilities:

• Actively participates in interviewing and hiring of the clinical team
• Actively participates in the training and onboarding of clinical colleagues
• Provides coaching and mentorship to a multi-disciplinary care team towards success in their jobs
• Makes territory assignments
• Collaborates with the clinical team in the management of selected high-risk patients
• Monthly ride alongs with clinical team
• 50 percent patient/colleague facing
• Completes unplanned, urgent, and/or emergent in-home visits as needed to meet patient needs
• Completes hospitalization reviews to identify root cause and develop an action plan
• Audits clinical documentation and provides feedback to clinical colleagues
• Participates in Multidisciplinary Team Meetings
• Communicates key performance indicators (KPIs) to direct reports (all Providers, Field Nurses, and Community Health Workers in their home-based medical practice)
• Holds direct reports accountable for KPIs
• Conducts regular team meeting with his/her direct reports
• Communicate closely with other healthcare providers so that primary and specialty care is well coordinated, including the use of virtual consult platforms
• Collaborations with Behavioral Health Care Manager in regions as is relevant
• Ensure accurate and thorough clinical documentation for all patients
• Lead clinical education and quality improvement activities and meetings at the market level
• Completes performance evaluations for all direct reports
• Communication Skills, knowledge of Motivational Interviewing
• Must have a strong desire to build close relationships with all members of the field and regional teams.
• Must be committed to working in a collaborative relationship with the members primary care provider.
• Excellent time management, organizational skills, and strong communication is a must.
• Other Duties as assigned

Qualifications

Role Qualifications:

We are searching for a special breed of health care professional who embodies the following qualities and characteristics: heart and commitment to serve vulnerable populations, passion, and perseverance to achieve long-term goals (a.k.a. grit), team-based and social determinants of health orientation, and embrace change in a rapidly evolving health care delivery system. Flexible and dynamic, this self-starting individual will be a creative problem solver with a proven track record of successful implementation of innovate health care delivery solutions. They must possess excellent time management and organizational skills, with the ability to prioritize and multi-task. Additional qualifications include-

• Holds active, unencumbered license in state of practice
• Credentialed in adult, family, or geriatric care
• Has active DEA license
• Experience in care of adult, chronically ill patients
• Five or more years of practice experience preferred
• 2 or more years of direct management experience preferred
• Current Certification in AHA or ARC Basic Life Support for health care providers required for employment
• Ability to navigate and use an electronic health record for documentation, and working knowledge of computers and ability to document effectively and efficiently in an electronic health record system
• Driver’s license requirements: licensed for a minimum of 3 years without restrictions; no DUI or other felony driving conviction in the past 7 years

Emcara Health is an equal opportunity/equal access employer fully committed to achieving a diverse workforce.