TRANSITIONS OF CARE, RN

Summary

This position is responsible for coordinating behavioral, medical, social, and dental health care needs for all AllCare Medicaid, Medicare, and Medicare dual eligible members of all ages during transitions from one health care setting to another, or from home, to or from, a healthcare setting; this includes members with terminal conditions requiring goals of care and advance care planning support, and members planning a future surgery occurrence by performing the following duties.

Essential Duties

1. Assess, plans, implements, coordinates and requests services required to meet member health care needs. 
2. Interacts with the member, family, caregiver, and involved healthcare professionals when Goals of Care cases are determined to exist with the purpose of advocating for member decision making and providing adequate education to support member in understanding which choices are available to them, including periodic re-evaluation of individual and family nursing needs for participants who have a terminal diagnosis and a prognosis of 6 months or less. 
3. Coordinates with receiving facility for planned transitions from any setting to any other setting, or unplanned transitions, such as an emergency department visit leading to a hospital admission. 
4. Acts as an advocate and facilitates collaboration with the interdisciplinary care team (ICT) in order to assist members to develop a knowledge base that will allow self-reliance in coping with chronic illnesses
5. Conducts thorough planning to determine and document specific objectives, goals, and actions to meet the member’s identified needs, including re-evaluation of the individualized care plan (ICP). 

Job Duties

• Serves as subject matter expert in care coordination and case management interpreting regulatory requirements and coordinates the process to support those requirements.
• Understands and has working knowledge of the regulatory requirements from CMS and OHA regarding the frequency of member interactions during transitions.
• Completes thorough assessments to collect in-depth information about member situations in order to identify their individual needs.
• Develops a comprehensive case management plan based on initial assessment and adjusts as necessary.
• Implements plans by executing and documenting specific interventions, activities and/or tasks that will lead to accomplishing the established goals.
• Organizes, establishes, integrates, updates, modifies and documents the resources necessary to accomplish the goals established in the care management plan.

Clinical Supervision

• This position provides clinical supervision for assigned clinical personnel and other support staff. 
• Supervision needs will be evaluated based on clinical experience and performance and may be weekly but not less than bi- weekly.

• Acts as preceptor during the onboarding of new hire employees.

Job Requirements

• May require the use of personal vehicle for local travel (subject to mileage reimbursement).

Qualifications

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

All health care providers who are HIPAA covered entities, whether individuals or organizations, must obtain an NPI number. Under HIPAA, you’re a covered health care provider if you electronically transmit health information in connection with a HIPAA standard transaction, even if you use a business associate to do so. AllCare Health employs staff that are defined under OHA or CMS as health care providers. Positions that are defined as providers include, but are not limited to, Doctors, Nurse Practitioners, Physical Therapists, Traditional Health Workers, and Certified or Qualified Healthcare Interpreters.

Education & Experience

• Associates or Bachelor's degree from an accredited university in nursing. 
• Knowledge of behavioral health and psychiatric disability issues, psychological and neuropsychological issues, substance abuse, addiction, wellness and illness prevention, multicultural issues, chronic illness and disability aspects, spirituality as it relates to their health, complementary alternative medicine management, and members in various stages of crisis is preferred. 
• At least two years of experience in case management, disease management, managed care, or homecare coordination. 
• Knowledge of appropriate referrals to QI Committee, Corporate Compliance, Fraud and Abuse, Appeals and Grievances.

Certificates, Licenses and/or Registrations

• Valid Oregon Registered Nurse (RN) licensure. 
• Valid Oregon Driver’s License and vehicle insurance. 
• Completes the National Provider Identifier (NPI) registration within the first 30 days of hire. 
• Current Basic Life Support (BLS) Certification or willingness to be certified within 90 days of hire.
• Current Mental Health First Aid Certification or willingness to be certified within 90 days of hire.
• CCM certification is required or to be obtained within two years of hire date. (Subject to pay increase upon Certification)

Language Skills

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.

Mathematical Skills

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Computer Skills

Job requires specialized computer skills. Must be adept at using various applications including database, spreadsheet, report writing, project management, word processing, presentation creation/editing, communicate by e-mail and use scheduling software. 

Reasoning Ability 

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Interpersonal Skills

• Effectively and professionally communicates with team members and customers.
• Wants to learn.
• Collaborates with teammates to provide professional service to customers.
• Maintains an attentive and empathetic demeanor.
• Takes initiative and is resourceful. 
• Uses discretion, tact and good judgment.
• Copes with stressful and dynamic work situations, prioritizing multiple tasks while maintaining deadlines.
• Self-resolves most conflicts or misunderstandings with minimal need for direct supervision.
• Effectively work with people with mental illness and from diverse backgrounds and experiences.
• Applies patience and listening skills to respond appropriately and interact positively with upset customers. 
• Creates a pleasant experience for all customers, such as being personable and attentive.

Physical Demands & Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this job. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

The employee must occasionally lift and/or move up to 10 pounds. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. The employee is occasionally required to stand; walk and reach with hands and arms. The noise level in the work environment is usually moderate.

• The employee has exposure to communicable disease and body fluids.
• Because of exposure to patient records of all types, the highest standard of patient confidentiality and privacy as established by business policy and HIPAA requirements must be maintained.
• The employee must be able to work onsite for all scheduled shifts, occasionally, frequently, as needed.
• The employee must be able to travel locally, as needed.