About Job

Description

Department : Population Health

Position : RN Care Manager— HAN (Health Access Network)

Employee Category : Non-Exempt

Reporting Relationship : Population Health Manager

Character Qualities

Alertness — Being aware of what is taking place around me so I can have the right responses.
Dependability — Fulfilling what I consented to do, even if it means unexpected sacrifice.
Flexibility —Willingness to change plans or ideas without getting upset.
Sensitivity— Using my senses to perceive the true attitudes and emotions of others.

Summary Of Duties And Responsibilities

The RN Care Manager – HAN (Health Access Network) is responsible for all aspects of nursing care for patients with chronic medical and/or behavioral health conditions. This RN partners with patients and their caregivers, physicians, nutritionists, educators and the entire health care team to provide timely access to care with continuity across all settings, linkages to long-term supportive services and community resources, and participation in informed and shared decision making.

Primary Duties And Responsibilities

Telephonic Care Management:

Demonstrates and applies principles of person-centered, strength-based philosophy, motivational interviewing, shared decision making, health coaching and adult learning principles.
Demonstrates a sensitivity and responsiveness to a variety of cultural values, beliefs and social determinants of health.
Facilitates access to health care providers, staff and resources.
Assists patients to utilize the Variety Care patient portal.
Links patient and caregiver to supportive community services as needed and follow up to confirm contact.
Facilitate access, communication and collaboration between patients and all providers.
Maintains accurate records to document and monitor the care coordination activities in the electronic healthcare record (EHR).
Acts as primary liaison between staff and patients.
Participates in regular case staffing meetings and reviews.
Monitors identified performance measures and deliverables and provides regular progress reports. -Report submission will be determined as performance measures and deliverables are identified.

Community And Clinic Based Care Management

Fulfills all tasks associated with Telephonic Care Management.
Provides basic assessment of health and mental health status, functional abilities, caregiver stability, social supports, financial resources, environment and safety concerns, life care planning and self-management skills.
Facilitates the development of comprehensive shared plan reflecting patient goals and preferences, self-care, and evidence-based best practice for multiple chronic conditions.
Assess barriers to achieving these goals.
Assess patient’s strengths and confidence in achieving goals.
Conduct ongoing medication reconciliations including assessing barriers.
Monitor and evaluate plans including progress toward goals, health status, barriers to achieving goals, medication reconciliation, provide disease management education and health coaching.
Provides and coordinates transition services across all settings of care.
Recognize and communicate signs and symptoms of change in a patient’s health status or mental health needs.
Crisis management.
Provides contact with patients through telephonic, clinic visits, medical and psycho-social appointments, home visits, and hospital visits.
Communicates care plan to all providers in all settings of care (ED, hospital, rehabilitation facility, home care, nursing home and specialists).
Ensures patients, caregivers and providers receive timely information for treatment decisions across all settings.
Coordinates/verifies that services, equipment and needed supplies are in place.
Reconciles patient’s medications accurately and routinely.
Utilize critical thinking to assess alternative approaches to problems and/or decisions.
Conduct assessments and monitoring within prescribed timelines.
Participates in team meetings to review individual and population-based outcomes, patient experiences, and identify opportunities for practice improvement.
Communicates with other providers (e.g., specialists, respiratory therapists, nutritionists, physical therapists, home health providers, care managers, and social workers) by optimizing the office-based care team to send, receive, and triage information flows among the providers.
Supports Variety Care’s accreditation as a Patient Centered Medical Home and our commitment to provide care to all Variety patients that is Safe, Effective, Patient Centered, Timely, Efficient, and Equitable. Provide leadership and work with all staff to achieve the goals of the “Triple Aim” of healthcare reform—to improve the experience of care, improve health outcomes, and decrease healthcare costs.
Embodies the strength of personal character. Places value on being an open and honest communicator who displays high moral and ethical conduct, integrity, adaptability, and sound judgment. Must be a leader in the department and community. Result-oriented problem solver who is responsible and accountable.
Performs other duties as assigned.

Community Representative

Serves as the Variety Care representative on community boards and task forces.

Qualifications

Requirements, Special Skills or Knowledge :

Active RN License in good standing in the state of Oklahoma.
Completion of the OSDMHSAS Behavioral Health Care Management Certification required within six months of hire.
Excellent oral and written communication skills.

Preferred Requirements, Special Skills Or Knowledge

Bachelor of Science in Nursing degree and at least two years of experience in care management in a community-based nursing or social work/health services care management.
Bilingual (English/Spanish).

Essential Functions