Under the direction of the Director of Care Management, the RN Care Manager is responsible for managing high-risk, chronic illness members to promote effective education, self-management support, and timely healthcare delivery to achieve optimal quality and financial outcomes. The RN Care Manager will formulate and implement a care management plan that addresses the members identified needs by assessing issues, resources, and care goals. The RN Care Manager will advocate for the member and support the member in navigating the health care system. Additionally, the RN Care Manager will work collaboratively with the interdisciplinary team and members PCP / Health Care Team to identify and support the achievement of the member's short-term and long-term health goals. HTA’s Care Management model is to provide longitudinal care management for identified members. Based on the RN’s work experience in nursing and knowledge of the health care system, the aims are to provide education and resources to members to ultimately reduce preventable emergency room visits and hospitalizations, and re-admissions.
ESSENTIAL JOB FUNCTIONS
- Collaborates with providers and practice staff in identifying appropriate members for care management, utilizing established Care Management criteria.
- Performs initial and periodic holistic assessments for the identified care-managed populations. This includes physical and psychological concerns for members as appropriate. The assessment includes a systematic and pertinent collection of data about the health status of the member. Prioritize members according to intensity, need, and required follow-up.
- Formulates and implements a care management plan that addresses the member’s identified needs by assessing the member/family needs, issues, resources, and care goals; determining the choices available to individual members; educating the patient/family on the choices available to meet their goals.
- Establishes a care management plan that is mutually agreed upon by the health care team and the member/family. Plans specific mutual self-management goals and objectives and interventions with the members that are action-oriented.
- Evaluates the effectiveness of the plan in meeting established care goals; revise the plan as needed to reflect changing needs, issues and goals. Monitors and evaluates the progress of the member at prescribed minimal intervals.
- Collaborates with the healthcare team to revise the care management plan when changes occur. Initiates / participates in care conferences to discuss multidisciplinary team responsibilities, member progress, new problems, etc.
- Identifies and effectively utilizes community resources to meet the needs of members/families. Facilitates member access to community resources as appropriate and/or refers to SW.
- Promotes member self-management and empowers members/families to achieve maximum levels of wellness and independence. Interacts professionally with member/family and involves member/family in the formation of the plan of care.
- Performs follow-up calls for members recently discharged from acute hospitalizations and who are considered to be at high risk for readmission.
- Collaborates with providers, and other healthcare team members including inpatient facilities, outpatient providers, and the Utilization Management department to transition care and facilitate care across the healthcare continuum and optimize clinical and financial outcomes.
- Determines and completes appropriate referrals. Serves as a liaison to providers, members, and families for coordination of services.
- Maintains accurate and timely documentation. Ensures documentation meets current standards and policies.
- Strives to meet established standards for productivity.
- Participates in regular team meetings and peer review activities. Participates in departmental and organizational committees, as applicable. Assists/supports in the orientation of new personnel. Promotes collaborative teamwork.
- Meets with the care management team leader (Director of Care Management) and the care management team on a regular basis to provide member updates identify issues and develop strategies for resolution.
- Performs all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with basic principles and guidelines of professional nursing.
- Maintains appropriate professional boundaries.
- Maintains a working knowledge of, and adheres to applicable federal and state regulations including, but not limited to, laws related to patient confidentiality, the release of information, and HIPAA.
- Interacts harmoniously and effectively with others, focusing on the attainment of organizational goals and objectives through a commitment to teamwork.
- Conforms to acceptable attendance and punctuality standards as expressed in the Employee Handbook.
- Abides by the organization’s compliance program and requirements.
- Current on all required training for the current year.
Major Work Activities
Coordinates care provided to a community-based high-risk population as follows:
- Ability to effectively engage members by telephone to conduct thorough screening, and physical and psychosocial assessments on a community-based caseload of members in a timely manner.
- Consistently collaborates with members and families, physicians, and other health care team members to identify physical and psychosocial issues or barriers that affect health condition management
- Implements a comprehensive patient-centered plan of care to proactively manage these issues and effect positive health outcomes
- Prioritizes caseload to balance member and departmental needs.
- Acts as a member advocate and coordination link with other health care providers and community resources to positively impact outcomes.
- Advocates for the member to overcome barriers and resolve benefits issues. Assist members in navigating the healthcare system and insurance benefits
- Thoroughly assesses each member’s eligibility for needed resources.
- Risk stratifies members and identifies barriers or gaps in treatment and refers to the appropriate team member to address the need as indicated to holistic care positive outcomes.
- Stays abreast of community resources and refers the Member for services and assistance when appropriate.
- Willingly collaborates with health care team members to formulate an individualized care plan and goals that best meet the needs of the family/member.
- Utilizes motivational interviewing techniques to engage members in goal setting.
- Updates Care Enrollment to articulate current short-term and long-term goals as well as when these goals are met and/or revised.
- Consistently communicates with the health care team members to ensure patient care needs are addressed in a timely manner.
- Communicates care coordination and key elements to providers per department requirements.
Monitors member's adherence to treatment plans as follows:
- Consistently monitors adherence to the member's treatment plan and relays issues to appropriate care providers promptly and effectively.
- Proactively identifies barriers to adherence and acts promptly to revise the treatment plan to improve member adherence and outcomes
- Takes prompt action when issues involving the appropriate and cost-effective utilization of resources are identified, collaborating with appropriate health care team members
- Confers with the members/families, physicians, and other care providers and insurance carriers in the role of patient advocate, as needed to resolve benefit issues and secure necessary services
Provides documentation of telephonic disease management activities as follows:
- Consistently documents all care management activities in the Care Enrollment Record(s) and or software applications using the established format in a timely and accurate manner per department requirements
- Promptly sends reports and communications to physicians and other providers as per department requirements and as needed to relay pertinent findings.
- Actively participates in program improvement activities
Provides Health education as follows:
- Considers teaching methods based on individual needs/differences.
- Utilize a variety of approaches to effectively educate members/families as well as other members of the health care team regarding community resources, health care benefits, and insurance and managed care issues
- Follows-up to evaluate the effectiveness of the education provided and documents
- Participates in multidisciplinary patient care conferences as needed
- Consistently and accurately documents health education activities in the documentation system per department requirements.
- Appropriately updates departmental leadership with necessary information
- Assists in program development and group education
- Supports training of new telephonic staff members
- Performs other duties as assigned.
Associated degree in nursing
Registered Nurse licensed in North Carolina or a Compact state.
- Current NC RN licensure in good standing
- Annual Flu Shot
- COVID-19 Vaccine
- Five years of nursing-related care experience and/ or home care experience combined.
Required Knowledge, Skills, and Abilities
- Knowledge of care management concepts along the continuum
- Knowledge of Medicare benefits
- Experience and ability to use Microsoft Office products and word-processing software on a daily basis
- Excellent written, verbal, and listening communication abilities. Communicate appropriately and clearly to members, coworkers, and providers.
- Ability to manage conflict, stress, and multiple simultaneous work demands in an effective and professional manner.
- Ability to successfully articulate the process of attaining goals and outcomes of care management
- Ability to apply clinical knowledge and experience in a care management role
- Ability to engage and collaborate with the member and significant others in the care management process
- Ability to care to manage diverse populations without applying one’s own personal values
- Ability to work with minimal supervision within the nursing scope of practice
- Ability to think critically and analytically and work with minimal supervision.
- Ability to evaluate and appropriately respond to verbal and non-verbal communication from patients in diverse stages of development
- Ability to use good judgment to protect personal safety while performing duties
Preferred QualificationsPreferred Education
- BSN or Advanced Degree in Nursing
Preferred Licensure/Certification Regulatory
- Case Management Certification desirable.
- Case Management, Care Management, Telephonic Case Management, and/or Disease Management experience
Preferred Knowledge, Skills, and Abilities
- Advanced clinical knowledge.
- Skills related to physical assessment, wound care, blood pressure monitoring, CBG checks, and Foley Cath care. Clinical knowledge and ability to educate clients of all ages about the following core disease management issues: Diabetes, Hypertension, Hyperlipidemia, CAD, Asthma, COPD, and renal disease required. (This is not intended as an inclusive list of all conditions.)