Care Manager, Home Health RN

Mountain Area Health Education Center - MAHEC•Asheville, NC

3d•$34•Onsite

About The Position

JOB SUMMARY: The Care Manager, Home Health RN is a specialized Mobile Integrated Healthcare Provider that operates in an expanded role to provide an array of routine and advanced health services to underserved and/or medically fragile patient populations. The role is responsible for provision of care in the patient's home setting by using assessment, planning, implementation, and evaluation techniques in accordance with the policies, protocols, and procedures and under the supervision of the patient referring provider. They will demonstrate sensitivity to needs of culturally diverse populations by providing appropriate sound judgement in a professional manner to coordinate care, remove barriers in accessing and appropriately utilizing health services. The role is supervised by the Manager of Care Management and serves as a member of a multi-disciplinary care team comprised of Physicians, PA’s, Nurses, Pharmacists, Care Managers, Care Navigators, Behavioral Health Professionals, Respiratory Therapists, and other specialists. This role works collaboratively with the patient and stakeholders to assist in identifying and addressing gaps in the patient’s care, access to care, transitions of care, patient safety and to enhance their overall resiliency and quality of life. The role serves as an educator and coordinator for the patients, their families and for the community in ensuring the highest possible health equity. SPECIFIC RESPONSIBILITIES: Assists patients primarily in their place of residence with navigating transitions of care, accessing care, medication reconciliation and health promotion through understanding of and participation in their care plan. Conducts patient visits that meet MAHEC guidelines. Coordinates arrival to scheduled patient visits with pre-notification of patient and arrives at agreed upon time. Promotes patient safety in all aspects of patient care environment. Documents and reports all findings as requested in EHR, care management platform and data collection software. Conducts visits as scheduled to complete assessments and follow up Works as part of multidisciplinary care team Interacts with physicians, care managers, care navigators, social workers or other referring professionals to report findings and assist in connecting patients with services. Ensure information is communicated in a timely manner to all members of care team. Provides basic and advanced level care based on a combination of referring physician orders and treatment protocols, procedures, policies and medications approved by the licensing board. Supports Medication Review and Reconciliation Obtains necessary tests and evaluation including but not limited to 12 and 15 Lead EKG, Pulse Oximetry, SP and SP Met, Blood Glucose, lab draws, pulmonary function tests and fetal heart tones based on provider orders and follows Mission Health System guidelines pertaining to sample integrity, handling, labeling and delivery to the lab. Facilitate and assists with telehealth visits Completes other testing and screenings as directed by the physician or care manager responsible. Communicates abnormal findings to the responsible care manager and/or Physician in a timely manner. Initiates 911 and begins initial BLS and ALS treatment and monitoring of patients deemed unstable and requiring transport to definitive care. Interprofessional and Person-Centered Planning to determine specific objectives, goals and actions designed to meet the patient's needs as identified through the assessment process. The plan should be action oriented and time specific. Provides patient centered care and support of care plan Collaborates with key professionals (Physicians, Advanced Practice providers, Nursing staff, Social Workers, Care Managers, Care Navigators, Palliative Care, Wound Care, etc.) to formulate patient's plan of care. Strategizes with the interdisciplinary care team to provide the safest, most cost -effective plan of care for post hospitalization, prevention, and discharge transition This role description is a general description of the essential job functions. It is not intended to describe all the duties the Care Manager, Home Health RN may perform.

Requirements

Communication Skills
Decision Making
HealthCare Knowledge
Interpersonal Skills
Organizational Values
Problem Solving
Excellent skills in Microsoft Office including Word, Excel, PowerPoint, and database applications required.
Must be competent with virtual (email, Webex, Zoom, Microsoft TEAMS etc.) communication, Electronic Health Record (EHR) systems and Care Management/Coordination systems.
Registered Nurse
Two (2) years of experience as a Registered Nurse and at least one (1) year of home health nursing experience.
Currently licensed by the North Carolina Board of Nursing as a Registered Nurse.
Valid NC Driver’s License
Current CPR certification
Regular attendance on-site is an essential function of this position.
Typical business hours are Monday – Friday, 8:00 am to 5:00 pm (or flexed to best meet the needs of the clients and/or the Division); 40 hours per workweek; weekend, holiday, or evening coverage is occasionally required.
Work hours will need to be flexible in order to respond to special work assignments, or evening activities, as requested by the team leader.

Nice To Haves

Spanish speaking skills preferred.

Responsibilities

Assists patients primarily in their place of residence with navigating transitions of care, accessing care, medication reconciliation and health promotion through understanding of and participation in their care plan.
Conducts patient visits that meet MAHEC guidelines.
Coordinates arrival to scheduled patient visits with pre-notification of patient and arrives at agreed upon time.
Promotes patient safety in all aspects of patient care environment.
Documents and reports all findings as requested in EHR, care management platform and data collection software.
Conducts visits as scheduled to complete assessments and follow up
Works as part of multidisciplinary care team
Interacts with physicians, care managers, care navigators, social workers or other referring professionals to report findings and assist in connecting patients with services.
Ensure information is communicated in a timely manner to all members of care team.
Provides basic and advanced level care based on a combination of referring physician orders and treatment protocols, procedures, policies and medications approved by the licensing board.
Supports Medication Review and Reconciliation
Obtains necessary tests and evaluation including but not limited to 12 and 15 Lead EKG, Pulse Oximetry, SP and SP Met, Blood Glucose, lab draws, pulmonary function tests and fetal heart tones based on provider orders and follows Mission Health System guidelines pertaining to sample integrity, handling, labeling and delivery to the lab.
Facilitate and assists with telehealth visits
Completes other testing and screenings as directed by the physician or care manager responsible.
Communicates abnormal findings to the responsible care manager and/or Physician in a timely manner.
Initiates 911 and begins initial BLS and ALS treatment and monitoring of patients deemed unstable and requiring transport to definitive care.
Interprofessional and Person-Centered Planning to determine specific objectives, goals and actions designed to meet the patient's needs as identified through the assessment process. The plan should be action oriented and time specific.
Provides patient centered care and support of care plan
Collaborates with key professionals (Physicians, Advanced Practice providers, Nursing staff, Social Workers, Care Managers, Care Navigators, Palliative Care, Wound Care, etc.) to formulate patient's plan of care.
Strategizes with the interdisciplinary care team to provide the safest, most cost -effective plan of care for post hospitalization, prevention, and discharge transition

Benefits

full benefits
MAHEC is a qualifying employer for the Public Service Loan Forgiveness (PSLF) Program. Employees who meet federal requirements may be eligible to have remaining student loan balances forgiven after 10 years of qualifying payments while working full-time at MAHEC.

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