RN Care Manager (Rocky Mount)

Summary: The RN Care Manager serves a critical role as a liaison between the central CMHN clinical team and the practice-based clinical team at member health centers. Responsible for ensuring timely prioritization and assessment of patients, the Care Manager engages patients to address the highest priority needs to achieve quality, cost-effective outcomes. , Planning appropriate interventions, coordinating with other care team members, both internal and external, monitoring progress toward patient and population goals, and evaluating the effectiveness of specific approaches with individual patients and high priority population segments are all core function of CMHN care managers. Particular attention to transitions of care is essential. Minimum Qualifications (Degrees/Certificates): Associate degree or better from an accredited School of Nursing. Licensed as a Registered Nurse (RN) with the state of NC. At least three years of experience providing care management, case management, or care coordination to a safety-net population. Certified Case Manager (CCM) Preferred. Preferred Qualifications: Medicaid Populations FQHCs

HEDIS

Care Gap Closure Telephonic Care Management Population Health SDOH Assessments Chronic Care Management Knowledge, Skills and Abilities: Excellent and effective written and oral communication skills. Proficiency in EMRs, Microsoft Office Outlook, Word, Excel, PowerPoint use and e‐mail communication. Ability to communicate clearly and succinctly. Dependable, manages time well; efficient and organized. Ability to produce accurate work; ability to perform multiple tasks in a proficient and timely manner. Demonstrate good supervisory and management skills Supervisory Responsibilities: Care Management Team (Care Coordinators) Essential Functions: Oversight of Care Management services and activities based on care management standards of practice for enrolled populations. Develop, review and Complete comprehensive assessments that are patient-centered and considers the total individual, inclusive of medical, biopsychosocial, behavioral, spiritual and cultural needs of the enrolled population, throughout the continuum of care to improve their health outcomes. Work with patients/caregivers, to identify and address behavioral, social, cultural, and environmental strengths and barriers as it relates to his/her diagnosis, treatment, and access to care. Implement Care Management interventions, set goals, and develop the plan of care based on transitional care discharge plans/instructions, the comprehensive assessment and patients’ goals. Implement patient-centered plans using therapeutic skills and techniques such as, motivational interviewing, strengths-based, and solution-focused modalities. Facilitate and provide education to patient/family about clinical diagnosis, medications, available resources, prevention, and risk factors to achieve optimal self-management. Monitor quality and effectiveness of interventions to the enrolled populations by setting patient-centered SMART goals in collaboration with the patients’ and families’ identified goals. Delegates tasks and referrals to members of the care management team appropriately, accurately, and timely according to established workflows. Serve as an advocate and liaison among the patient/family, community services, primary providers, specialists, and other care team members to coordinate services. Work collaboratively with multi-disciplinary team members to facilitate achievement of desired health outcomes. Maintain appropriate and timely documentation in the Care Management documentation platform, in accordance with organizational policies and procedures. Engage and maintain collaborative relationships with community provider agencies that promote quality care and cost-effective health care utilization. Adhere to NCCHCA privacy and security policies to ensure that patient and network data are properly Abide by department guidelines, company policies, and HIPAA regulations. Attend departmental and corporate meetings, local and regional training, or other events as required. Will go on-site to health centers as needed to coordinate with the clinic-based care team and/or patient and family. . Support organizational goals and objectives in meeting performance improvement targets for various initiatives, programs, and standards of care. Review care management productivity and clinical performance data to assess and support care management priorities and determine appropriate interventions. Ensure standardized plans of care expectations, and team development, to ensure standards related to assessment and care plan standards and organizational and team goals are met. Manage and supervise team members to ensure work is done timely and accurately. All staff work at the top of their license/certification. Willingly perform other duties as assigned. Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to stand, sit, talk, hear, and use hands and fingers to operate a computer and telephone keyboard, reach, stoop, and kneel. Specific vision abilities required by this job include close vision requirements due to computer work and distant vision requirements. Light to moderate lifting is required. Ability to uphold the stress of traveling. Regular, predictable attendance is required Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Moderate noise (i.e., business office with computers, phone, and printers, light traffic). Ability to work in a confined area. May work remotely as defined by the health center or NCCHCA policy. Ability to sit at a computer terminal for an extended period or drive distances. Must have an operational automobile and current active NC drivers’ license and auto insurance. The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required of the position. All employees may have other duties assigned at any time. #J-18808-Ljbffr North Carolina Community Health Center Association