About Job

Job Description

Job Summary:

The RN Care Manager addresses the needs of the population served by assessing, planning, implementing, coordinating, monitoring, and evaluating the options and services required and using communication and available resources to promote quality, cost-effective health outcomes. Works within the Registered Nurse scope of practice, and in concert with the Primary Care Provider, patient, caregivers, family members, other members of the Care Management Team and the community to coordinate a full continuum of health care services considering the holistic needs of the member, inclusive of unique social and cultural dynamics. In addition, this position will support CCHC goals and objectives in meeting performance improvement targets for various initiatives, data analysis that supports care management, standardized plan of care expectations, and patient team development and perform other duties as assigned like the occasional need to triage patients to support the development of the network.

Responsibilities:

Provide effective Care Management services based on case management standards of practice to enrolled populations
Complete comprehensive assessments considering the total individual, inclusive of medical, biopsychosocial, behavioral, spiritual and cultural needs to enrolled population, throughout the continuum of care
Develop, review, and evaluate the member care plan in partnership with the member, caregiver/family members, providers, and Care Management team members, as applicable
Work with patients to identify behavioral, social, cultural, and environmental strengths and challenges as it relates to his/her diagnosis, treatment, and access to care.
Occasional need to triage patients.
Identify and address barriers that impede health outcomes
Implement Care Management interventions per the patient’s care plan
Work in conjunction with patient to formulate, develop, and implement patient-centered plans using therapeutic skills and techniques such as trauma-informed care, motivational interviewing, strengths-based, and solution-focused modalities.
Provide education to patient/family about clinical diagnosis, medications, available resources, prevention, and risk factors to achieve optimal self-management
Utilize therapeutic skills and techniques to help patients achieve healing, growth, health, and wellness
Monitor quality and effectiveness of interventions to the enrolled populations by setting patient-centered SMART goals in collaboration with the patients/families
Processes referrals to members of the patient engagement team (social work, behavioral health, community resource coordinators) and/or clinical team (pharmacy, pharmacy technician, patient coordinator) appropriately, accurately and timely according to established workflows
Serve as a liaison among the patient/family, community services, primary providers, specialists, and
other care team members to coordinate services without duplication
Work collaboratively with multi-disciplinary team members to facilitate achievement of desired treatment outcomes
Maintain appropriate member 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 CCHC privacy and security policies to ensure that patient and network data are properly safeguarded
Abide by department guidelines, company policies, and HIPAA regulations.
Attend departmental and corporate meetings, local and regional training's, or other events as required
Willingly performs other duties as assigned.
Works under the direct supervision of the Director of Nursing

Qualifications:

Licensed and credentialed Registered Nurse from an accredited school of Nursing with unrestricted licensure
Bilingual preferred, but not required
3-5 years’ experience in clinical or community resource settings with; care coordination and/or case management experience
Evidence of essential leadership, education, counseling skills, and strong interpersonal skills; ability to work with colleagues across sites.
Proficiency in communication technologies (email, cell phone, etc.)
Highly organized with ability to keep accurate notes and records
Experience with health IT systems and reports is desirable
Local knowledge about and connections to community health care and social welfare resources is desirable
Bilingual in English and Spanish is preferred but not required
Current BLS certification (or earned within 90 days of hire)
Ability to travel to other clinical sites when needed

Special Skill Requirements:

Core values consistent with a patient- and family-centered approach to care
Demonstrates professional, appropriate, effective, and tactful communication skills, including written, verbal and nonverbal
Demonstrates a positive attitude and respectful, professional customer service
Acknowledges patient’s rights on confidentiality issues, maintains patient confidentiality at all times, and follows HIPAA guidelines and regulations
Proactively acts as patient advocate, responding with empathy and respect to resolve patient and family concerns, and recognizes opportunities for improvement to meeting patient concerns
Proactively continues to educate self on providing quality care and improving professional skills
Must be able to interact with individuals of all cultures and levels of authority.
Requires the ability to maintain confidentiality.
Must be able to function as part of a team.

Charlotte Community Health Clinic, Inc. is an Equal Opportunity Employer. We do not discriminate in any aspect of employment with regard to age, race, sex, national origin, disability, color, marital status, veteran’s status, or religion.

Company Description

Started in 2000 by a group of committed volunteers, Charlotte Community Health Clinic is a Federally Qualified Health Center (FQHC) that offers high-quality medical, dental, and behavioral health services for children and adults.

Although we serve all populations, as a FQHC, we have a special purpose of serving the underserved. We work towards a healthy community where all individuals, regardless of ability to pay, have access to affordable, quality, and comprehensive health care. We accept most major health insurance plans, as well as Medicaid and Medicare. For patients without health insurance, we offer a discount program based on income and family size.

Our organization is growing! We are thrilled about the expansion of care that our growth allows us to provide. Our goal is to recruit, develop, and retain a team that not only meets the minimum job qualifications, but shares our passion for serving those who need it most.

For more information about us, use the link below:

https://charlottecommunityhealth.org/en/