RN Care Manager, Population Health

Mountain Area Health Education Center - MAHEC•Asheville, NC

About The Position

JOB SUMMARY: The RN Care Manager works collaboratively as an active member of the Population Health Administration as part of an interprofessional primary care team to provide comprehensive, person-centered care management services for patients that include: Patient education Medication management and adherence support Risk stratification Population management Coordination of care transitions Care Navigation and referrals This is a bilingual position and candidates with Spanish and English fluency are encouraged to apply. Care Managers will support patients with outreach, scheduled care management and triage response as needed. This role will systematically and continuously collect and assess data related to patient health status to develop, execute, and evaluate the plan of care. Required care management activities also include care coordination, health promotion, family support, and referrals to necessary resources and supports. These functions may be performed throughout WNC in community-based settings, during home visits if applicable, and in MAHEC clinics and remotely. The Care Manager will collaborate with Complex Care Managers and Tailored Care Managers, Extenders (Peer Support Specialists, Community Health Workers), Care Navigators, MAHEC clinical teams, community partners, and other regional and state stakeholders. At times the role may also cross over to Tailored Care Management and support patient overflow. SPECIFIC RESPONSIBILITIES: Conduct intake assessments, screenings and obtain necessary consents. Develop person-centered care plans with Primary Care Providers and with guidance from supervisor and other clinical experts as needed. Provide self-management education and bridge resources/services that are supportive of social and medical needs. Support transition planning when patients are admitted/discharged from hospitals or other institutional settings. Provide patient consultation in adapting treatment goals, identifying strengths, creating action items and addressing barriers to goals. Builds and maintains a full patient panel by actively identifying patients who qualify for program benefits and initiate's outreach. Develops outreach and engagement strategies to engage qualified patients. Complete referrals for unmet social determinant of health needs Educates providers and clinical staff on program services, identifying qualified patients, and patient engagement tactics. Work with MAHEC’s Quality Improvement team to improve care management delivery and patient outcomes. Ensure required care management data and metrics are documented, tracked, and reported successfully to meet quality standards and guarantee closure of care gaps. Collaborate with MAHEC’s clinical departments (Family Medicine, Internal Medicine, Pharmacy, OBGYN, and Psychiatry) and community resource organizations to ensure seamless care coordination/management for the population being served. Coordinate and may facilitate integrated Care Team meetings where patient Care Plan is discussed. Create a Care Management Crisis Plan and coordinate diversion efforts for patients at risk of admission to an institutional setting. Identify system barriers and collaborate to resolve issues with MAHEC departments and with community stakeholders. Collaborate with MAHEC’s QI, central billing office (CBO) and audit team to perform regular claim review and education This role description is a general description of the essential job functions. It is not intended to describe all the duties the Care Manager may perform. KEY COMPETENCIES: Communication: skills Effectively and respectably communicate with other individuals, whether it be a colleague, patient, or patient’s family member and appropriately enumerate information in a manner easily understood by all parties. We do this to foster a culture of understanding between all parties, especially in complex and difficult situations, to ultimately provide the best care possible to our patients and their families. Decision Making : Ability to make the most appropriate decision in a given situation and then taking the next steps to ensure appropriate and timely completion. This requires conflict resolution skills, critical thinking skills, confidence in your ability to make the right decision in most situations. This also includes ability to prioritize your workday appropriately to ensure the most important tasks are completed on time. HealthCare Knowledge: Having the drive to keep yourself abreast and up to date on the new breakthroughs in your area of expertise and communicating them to the rest of the team, as appropriate. This also includes keeping up with your licensure and yearly training requirements within your area expertise along with MAHEC’s organizational training. Finally, the ability to apply the depth of knowledge maintained and gained through this process in real life scenarios as appropriate. Interpersonal Skills: Showing the ability to meet difficult situations with grace, professionalism, and understanding. Within your area of expertise, showing respect and showing empathy where appropriate with your colleagues, patients, and their family at all times, even when its most difficult to do so. This is done, in part, by effective listening, being your authentic self, showing responsibility and dependability, and being patient with others. Organizational Values: Adherence to MAHEC’s founding principles and incorporating them every day. This includes, among others, having integrity and accountability, reverence for other cultures and equitable practices, ability to manage change, and displaying a clear understanding of organizational dynamics. Doing these things creates a culture where people want to do the best for each other and gives personal ownership towards the goal of helping people in their time of need. Problem Solving: Having an analytical mind and ability to work autonomously to solve complex problems that may arise. The wherewithal to think logically through a difficult problem and come to an appropriate resolution for a given issue. This helps to drive continuous improvement by thinking through where we can improve in a novel way. Measures success by understanding where we are currently and where we want to go and then applying those new ideas to affect positive change.

Requirements

Registered Nurse
Four (4) years of experience providing care management, case management, or care coordination services
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.
Valid NC Driver’s License
Valid RN License
Regular attendance on-site is an essential function of this position.

Nice To Haves

Spanish speaking skills preferred.

Responsibilities

Conduct intake assessments, screenings and obtain necessary consents.
Develop person-centered care plans with Primary Care Providers and with guidance from supervisor and other clinical experts as needed.
Provide self-management education and bridge resources/services that are supportive of social and medical needs.
Support transition planning when patients are admitted/discharged from hospitals or other institutional settings.
Provide patient consultation in adapting treatment goals, identifying strengths, creating action items and addressing barriers to goals.
Builds and maintains a full patient panel by actively identifying patients who qualify for program benefits and initiate's outreach.
Develops outreach and engagement strategies to engage qualified patients.
Complete referrals for unmet social determinant of health needs
Educates providers and clinical staff on program services, identifying qualified patients, and patient engagement tactics.
Work with MAHEC’s Quality Improvement team to improve care management delivery and patient outcomes.
Ensure required care management data and metrics are documented, tracked, and reported successfully to meet quality standards and guarantee closure of care gaps.
Collaborate with MAHEC’s clinical departments (Family Medicine, Internal Medicine, Pharmacy, OBGYN, and Psychiatry) and community resource organizations to ensure seamless care coordination/management for the population being served.
Coordinate and may facilitate integrated Care Team meetings where patient Care Plan is discussed.
Create a Care Management Crisis Plan and coordinate diversion efforts for patients at risk of admission to an institutional setting.
Identify system barriers and collaborate to resolve issues with MAHEC departments and with community stakeholders.
Collaborate with MAHEC’s QI, central billing office (CBO) and audit team to perform regular claim review and education

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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