Full-time (80 hours biweekly) Weekdays, daytime hours 8 am to 4:30 pm Hybrid Remote Work **Program Description:** WellSpan's Care Management team helps patients reach their best possible health in the right setting in a cost-effective manner. The Care Management team reviews benefits and resources, plus develops and puts into action a care management plan which includes goals, monitoring and follow up. The ambulatory outpatient care management team serves York, Adams, Franklin, Lancaster and Lebanon counties. The care management team typically works with patients via phone or video visits, and may also meet patients in their home, community or at their doctor's office. Depending on the type of care management program that the patient is enrolled in, the care manager typically works with patients for 1 to 6 months. **General Summary** Coordinates and monitors the health needs of patients, such as pain, symptom management, behavioral health, DME's, home health, assistance with daily living, and/or community resources. Conducts comprehensive assessments that include the medical, behavioral, pharmaceutical, and social needs of the patient, identifying gaps in care and barriers to attaining improved health. The Intensive Care Manager (ICM) works closely with patients, caregivers, family members, physicians, ambulatory care managers, hospital care managers, and ancillary service providers to achieve the patients maximum functional potential. This position provides on-going support through comprehensive assessment and care planning. The ICM ensures patients cases are in compliance with regulatory guidelines. **Duties and Responsibilities** **Essential Functions:** + Utilize Motivational Interviewing techniques as a patient-centered approach to activate patients in self-management of their chronic conditions with the goal of improved symptom management and interruption of a negative disease trajectory. + Maintains a caseload of patients per department guidelines and conducts outreach according to established protocols. + Identify, enroll and manage patients in program Intensive Care Management. + Develop and implement care plans to maximize healthcare outcomes and facilitate wellness with periodic review and update according to department protocols. + Perform medication review and teach-back to ensure patient understanding and ability to adhere to medical regimen. + Collaborate with PCPs, Specialists, and Hospitalists to effectively implement a patients-centered care plan. + Perform patient outreach according to established protocols and document in electronic medical record. + Identify, execute, and track needed referrals to care and community resources. + Provide resource management to improve care, patients experience and reduce unnecessary cost and utilization: right care, right place, right time. + Assists patients in navigating personal health decisions and care preferences, including but not limited to Advance Care Planning, to ensure individualized support and goal-aligned care. + Documents assessments, care plans, goals, and interventions in the electronic health record per accrediting body and departmental standards **Common Expectations:** + Prepares and maintains appropriate documentation as required, while maintaining established policies and procedures, objectives, quality assessment and safety standards. + Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation. + Attends meetings as required. **Required for All Jobs:** + Performs other related duties as identified. + WellSpan Health has adopted and implemented a compliance program to support WellSpan's values and standards for professionalism, integrity, and ethics. Expected to support and meet the values and standards of the organization and the performance expectations of the job, the department, and the compliance program. + WellSpan Health has adopted and implemented a privacy program to safeguard the patient information and the business and operational information of the organization. Expected to support and meet the values and standards of the organization to safeguard patient and business/operational information. The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. **Physical Demands:** + Standing - Occasionally + Walking - Occasionally + Sitting - Frequently + Reaching - Rarely + Talking - Frequently + Hearing - Frequently + Repetitive Motions - Occasionally + Eye/Hand/Foot Coordination - Occasionally **Working Environment:** + Occupational Hazards - Occasionally **Travel Requirements:** + Estimated Amount: 10% - **Qualifications** **Minimum Education:** + Associates Degree Required + Bachelors Degree Preferred **Work Experience:** + 3 years Relevant experience. Required + Experience in care management, or clinical nursing specialty. Preferred **Licenses:** + Licensed Registered Nurse Upon Hire Required or + Registered Nurse Multi State License Upon Hire Required and + Basic Life Support Upon Hire Required **Benefits Offered:** + Comprehensive health benefits + Flexible spending and health savings accounts + Retirement savings plan + Paid time off (PTO) + Short-term disability + Education assistance + Financial education and support, including DailyPay + Wellness and Wellbeing programs + Caregiver support via Wellthy + Childcare referral service via Wellthy For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org) (https://www.joinwellspan.org/benefits/) WellSpan Health's vision is to reimagine healthcare through the delivery of comprehensive, equitable health and wellness solutions throughout our continuum of care. As an integrated delivery system focused on leading in value-based care, we encompass more than 2,300 employed providers, 250 locations, nine award-winning hospitals, home care and a behavioral health organization serving central Pennsylvania and northern Maryland. Our high-performing Medicare Accountable Care Organization (ACO) is the region's largest and one of the best in the nation. With a team 23,000 strong, WellSpan experts provide a range of services, from wellness and employer services solutions to advanced care for complex medical and behavioral conditions. Our clinically integrated network of 3,000 aligned physicians and advanced practice providers is dedicated to providing the highest quality and safety, inspiring our patients and communities to be their healthiest. **Quality of Life** Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation. Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more - within an easy drive of major East Coast cities. York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000) WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic.