Case Manager II (Registered Nurse) - Population Health Medicare - Wilson Community Health Center

Carolina Family Health Centers•Wilson, NC

4d•Onsite

About The Position

Carolina Family Health Centers, Inc. is seeking a Case Manager II - Population Health Medicare to provide medical case management services to a specified panel of patients within the clinical setting. This position will also perform Medicare Annual Wellness Visits (AWV). The role involves floating between three health centers: Wilson Community Health Center, Harvest Family Health Center, and Freedom Hill Community Health Center. This position offers a 32-hour or 36-hour workweek, no weekends, a full benefits package, 12 paid holidays, a bi-annual bonus, and bi-weekly pay. Carolina Family Health Centers, Inc. is a nonprofit, federally qualified health center (FQHC) committed to providing accessible and affordable healthcare with excellence, believing that everyone deserves access to quality health care regardless of their ability to pay or insurance status. Their service offering includes primary medical care, behavioral health, pharmacy, and dental services in an integrated model.

Requirements

Graduate of an accredited school of nursing.
Current Registered Nurse license to practice in North Carolina.
Previous experience, preferably, in a community health center setting in the area of nursing and/or case management.
Active North Carolina Driver License.
BLS Certification.
Must have personal vehicle readily available for frequent travel between hospital, patient's home, and site-to-site visits.
Effective communication and interpersonal skills.

Responsibilities

Provide medical case management to medium/high-risk patients.
Perform annual comprehensive assessments to evaluate patients' health care needs and social determinates of health to develop individualized and person-centered care plans using a collaborative approach including patient and family participation, where possible.
Collaborate with community agencies for referral resources to assist patients and utilize NC Care 360.
Establish and document a care plan with the patient and/or family members.
Update and document care plans as the patients’ needs change and/or to address gaps in care.
Identify patients with recent emergency department visits or hospital admissions, and assists them with transitioning back to their primary care provider, including providing medication reconciliation and assisting with medication access.
Perform Medicare Annual Wellness Visits (AWV).