Nurse Case Manager

University of Oklahoma•Tulsa, OK

About The Position

The OU Sooner Health Access Network (HAN), housed within the Department of Medical Informatics, advances access to affordable, high-quality, person-centered care across Oklahoma. The program partners with primary care practices statewide and provides care management, quality improvement consulting, and education and training. Its interdisciplinary team of RN and LCSW care managers supports SoonerCare Choice and Aetna Better Health of Oklahoma members with complex medical and social needs through assessments, coaching, care planning, and connections to community resources. Services are provided through home and clinic visits, hospital coordination, phone outreach, and telehealth. The program is NCQA-accredited and grounded in evidence-based practices and coordinated care. The Nurse Case Manager assesses members’ medical, behavioral health, and social needs; works with members to develop and monitor individualized care plans; coordinates care and transitions across settings; and helps members and families understand conditions and treatments. The role also collaborates with providers and community services, documents activities in the management information system, participates in interdisciplinary reviews and quality improvement activities, and follows evidence-based protocols and prescribed timelines. The position represents OU on community boards and task forces. The work schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. Travel is not required. Pay is commensurate with education and experience. Benefits eligible: Yes.

Requirements

Bachelor’s degree in Nursing.
12 months of professional nursing experience.
State of Oklahoma Registered Nurse Certification.
An Associate’s degree in Nursing and 24 months of professional nursing experience may substitute for the Bachelor’s degree, for a total of 36 months of professional nursing experience.

Responsibilities

Collaborate with members to develop plans of care that identify goals, barriers, and strengths.
Assess members’ medical and behavioral health needs and social determinants of health, including functional abilities, social and environmental concerns, safety, caregiver stability, self-management skills, and life care planning.
Assess members’ strengths and confidence in achieving goals.
Conduct ongoing medication reconciliations and assess barriers to medication use.
Monitor and evaluate care plans, progress toward goals, health status, medication reconciliation, and member experience.
Review and interpret medical test results, therapist reports, and psychiatry reports.
Evaluate the effectiveness of medical treatments and recognize and communicate changes in members’ health and mental health status.
Provide member contact according to the applicable care management pathway, ranging from daily to at least monthly, including home visits, appointments, phone calls, hospital visits, and secure email.
Apply disease management and risk management concepts in service planning and use critical thinking to assess alternative approaches to problems and decisions.
Provide crisis management.
Connect members and caregivers with supportive community services and follow up to confirm contact.
Facilitate access, communication, and collaboration between members and providers.
Coordinate transition services across care settings; communicate care plans to providers; ensure members, caregivers, and providers receive timely information; coordinate or verify services, equipment, and supplies; and reconcile medications at every contact.
Maintain records of care management activities in the management information system.
Participate in interdisciplinary case staffing meetings and reviews.
Collaborate with providers and care teams, including specialists, therapists, home health providers, care managers, and social workers, to optimize information exchange and triage.
Communicate with, educate, and advise members and families about conditions and treatments.
Participate in quality improvement activities.
Monitor performance measures and deliverables and provide progress reports as identified.
Follow evidence-based protocols and conduct assessments and monitoring within prescribed timelines.
Apply person-centered and strength-based principles, motivational interviewing, shared decision-making, coaching, and adult learning.
Demonstrate sensitivity and responsiveness to cultural values, beliefs, and social determinants of health, and use a trauma-informed approach.
Serve as an OU representative on community boards and task forces.
Perform other duties as assigned.