RN Care Manager - ICCOA Medicare Program

HealthPoint Careers • Renton, WA

21d • Hybrid

About The Position

As part of the Integrated Care for Complex & Older Adults (ICCOA) Program, the RN Care Manager engages with a wide range of patients and families to deliver community home visits, telehealth support and focused patient outreach and coordination. This includes providing assessment, clinical care coordination, monitoring, and follow-up for a variety of services, supports, and clinical navigation primarily for people with Medicare (older adults or adults with disabilities). The RN Care Manager utilizes effective engagement, clinical assessment and navigation techniques to successfully engage patients in accessing appropriate care, obtaining community resources, and supporting the care team and organization to achieve success on various initiatives and contracts. This role will also partner with primary care teams to effectively close care gaps and support effective preventive and longitudinal care for patients, and may involve carrying a caseload of patients with complex needs. This is a new role at HealthPoint and will involve collaborating with the ICCOA team to establish and develop the role. The RN Care Manager provides clinical care management assessment, support, longitudinal care coordination and resource facilitation within an integrated interdisciplinary primary care team. The RN Care Manager evaluates, engages, and serves a population of patients with high risk and complex medical conditions and social barriers to wellness as a partner in the Population Health Dept who utilizes best practices, data and continuous process improvement to provide the most equitable individualized care possible. The posted compensation reflects the full pay range for the position. Individual offers are based on job requirements, candidate qualifications, including relevant skills and experience, applicable education, and internal equity.

Requirements

• Bachelor’s degree in Nursing from a four-year college or university
• three (3) years of direct-care nursing or equivalent combination of education and experience required.
• Previous experience in care management, care coordination, hospital setting, working with vulnerable populations, behavioral health or community health required.

Nice To Haves

• Master’s degree in Nursing (MSN)
• relevant certification
• bilingual language proficiency

Responsibilities

• Provide comprehensive nursing care management assessment, evaluation, triage, referral, and support to patients with complex medical, behavioral health and social needs by actively partnering with interdisciplinary care teams, focusing on overcoming social drivers of health and improving health equity.
• Develop, maintain, and advance individualized care plans with patients, focusing on individuals at high risk for poor health outcomes or avoidable high-cost care and actively facilitating achievement of health and wellness goals.
• Serve as an indirect-care clinical partner to the care team with a focus on medications, disease processes and progression, whole-person care and quality outcomes.
• Provide intake, longitudinal nursing care management and support to identified patients, including chronic condition treatment planning, urgent medical interventions, transition of care support, resource navigation, community resource procurement, care coordination, and emotional support.
• Evaluate acuity of needs and assist patients in overcoming barriers to optimal health and wellness, promoting graduation from care coordination when appropriate and maintaining appropriate patient panel size.
• Actively maintain engaged patient panel utilizing proactive person-centered techniques and approaches such as critical thinking, motivational interviewing, case finding, SMART goal setting, health coaching, patient-empowerment, relationship-building and proactive independent collaboration.
• Be committed to a continuous learning environment where programmatic goals will shift based on the healthcare environment, requiring flexibility and prioritization.
• Provide care coordination and nursing care management support for patients in various programs including pilot projects, grant-funded initiatives or other populations as identified in collaboration with leadership.
• Travel to various locations, including clinic, community, and home visits, as needed to provide care and support.
• Actively partner with care team members to provide nursing care management support and Nursing expertise especially for situations involving complex medical situations.
• Promote patient self-management, self-determination, and person-centered care.
• Facilitate care conferences, identify needs and connect to other interdisciplinary team members or specialties to support high quality patient care.
• Effectively collaborate with community partners and external organizations to promote health, wellness, effective coping and disease management of designated patient populations.
• Foster efficient delivery of care and services by assuring that effective communication exists between patients, their support system, and care teams.
• Respond to patient and care team requests promptly.
• Utilize the nursing care management perspective to administer screenings and assessments.
• Provide referrals for various risk factors or conditions to help guide and inform care plan and care support interventions or approaches, such as PRAP4ARE, PHQ-9, GAD-7, KATZ, PAM.
• Administer additional or advanced assessments as clinically appropriate.
• For patients eligible for specific programs through their insurance carrier, such as Health Homes for Medicaid, or through public or private funders, provide care and services in line with the requirements of the managed care organization, external entity, or funder.
• Complete any payer contract requirements including eligibility verification, coordination of appointments, attending required trainings, administering, and documenting screenings or assessments within required timeframes.
• Utilize patient-engagement skills to positively impact quality metrics, program, and clinical outcomes with designated patients.
• Be accountable for improving health outcomes, utilization rates, patient satisfaction, and self-sufficiency for a defined population of patients in alignment with evolving organization and population health goals for people with complex health and social situations.
• Maintain professional relationships and boundaries while supporting patients, families or caregivers with empathy, compassion and cultural congruence and maintaining respect for confidentiality, privacy, and mandated reporting.
• Identify and take appropriate action on patient safety situations, including assessing and facilitating patient safety planning, referrals and connections utilizing HealthPoint safety protocols, state, and local guidelines.
• Utilize clinical judgment and leadership support to facilitate appropriate connection to direct care for patients in crisis when indicated.
• Effectively assess and utilize appropriate communication modalities to maintain consistent and timely connection with patients, families and care team members including phone calls, video visits, clinic or home visits, and electronic communications as appropriate.
• Display emotional intelligence and continuously hone communication skills.
• Act as a change agent to address health disparities, improve health equity and advocate for person-centered approaches to care.
• Actively participate in population health approaches to patient care and support.
• Engage in data analysis and contribute to understanding health and social outcomes for patients, communities and within the care team.
• Document appropriately and timely in electronic medical record, databases, and other electronic systems as indicated.
• Demonstrate efficient and effective approaches to managing workload.
• Operates a motor vehicle on a regular basis to travel to various locations to perform a variety of functions which may include transporting goods, providing a service, or other tasks required for this position. Compliance with all traffic laws and company driving policies is mandatory. Responsible for paying any moving traffic violations and parking tickets received while performing job duties.
• Maintain good attendance, is punctual and works full scheduled shift is a condition of employment.
• Demonstrate respectful, professional, and appropriate behavior that supports a team-oriented work environment.
• Demonstrate a commitment to the mission, core values and goals of HealthPoint and its healthcare delivery including the ability to integrate values of integrity, wisdom, creativity, cooperation, responsibility and respect into appropriate programs and services.
• Other duties as assigned by supervisor.

Benefits

• Comprehensive health coverage – Medical, dental, and vision insurance for employees and eligible dependents, plus HSA and FSA options.
• Financial wellbeing – Employer-paid life insurance, AD&D, disability coverage, and a 401(k)-retirement plan with employer match.
• Time to recharge – Generous Paid Time Off (PTO), Extended Illness Time Away, eight (8) paid holidays, three (3) floating holidays, Compassion Time Away, and Opportunity Time Off for extended personal time away to rest and recharge.
• Well-being resources – Employee Assistance Program (EAP), employee wellness program, and access to voluntary benefits including supplemental life, critical illness, accident, identity theft, and pet insurance.
• Career development – Professional development, ongoing learning, and opportunities for career growth within a mission-driven organization.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level