RN, Care Manager (67498)

NorthCare•Oklahoma City, OK

42d

About The Position

The RN Care Manager - Registered Nurse who directly supports Variety Care's highest risk patients, with primary focus on at risk populations. In collaboration with other members of the healthcare team, the RN Care Manager is responsible for organizing, coordinating, and providing care management services, within the practice, who are at risk for health deterioration, poor health outcomes, and/or avoidable utilization of emergency care services.

Requirements

Active RN License in good standing in the state of Oklahoma.
Excellent oral and written communication skills.

Nice To Haves

Two years of experience in care management in a community-based setting.
Bachelor of Science Degree in Nursing is preferred.
Bilingual (English/Spanish).

Responsibilities

Manage Variety Care's high-risk patient population.
Conduct comprehensive assessment of patients' physical, mental, and psychosocial needs.
Develop care plans to prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, and minimize hospital and ER utilization.
Reconcile patient's medication list accurately and routinely.
Communicate with providers (e.g.; specialists, respiratory therapist, nutritionist, physical therapist, home health providers, care managers, and social workers) by optimizing the office-based care team to send, receive, and triage information flows among providers.
Utilize behavioral strategies including, but not limited to, Bridges out of Poverty, Crucial Conversations and Teach-Back techniques. Promote self-management goals that help patients adopt healthy behaviors and improves self-care.
Optimize the utilization of services available at Variety Care, including Behavioral Health, Social Services, Community Health Worker, Enrollment Services, Nutrition, Pharmacy, Optical and Dental.
Acts as a lead, for the care management team, of a subset of patients designated by the Population Health Manager, in coordination with the Director of Clinical Services. Assist the team (consisting of Social Services staff and Community Health Worker(s)) to prioritize and intervene effectively to keep patients medically stable and improve their quality of life as well as health outcomes.
Coordinates/verifies that services, equipment and necessary supplies are in place.
Participates in regular case staffing meetings and reviews.
Follow-up with patients within 24 hours of inpatient discharge and within 48 hours of emergency department visit notification.
Partner with external case management programs to coordinate care.
Provide on-going evaluation and documentation of patient progress and risk status.
Communicate and collaborate with internal care teams.
Accurately documents and monitor care coordination activities in the electronic health record.
Proactively support Variety Care's initiatives related to care coordination
Serve as a proactive member of care teams and team-based care initiatives.
Partner with Variety Care staff to develop integrated care management programs.
Serve as a professional role model for all staff.
Adheres to all Variety Care policies and procedures.
Supports Variety Care's accreditation as a Patient Centered Medical Home and our commitment to provide care to all patients that is Safe, Effective, Patient Centered, Timely, Efficient, and Equitable. Provides leadership and works with staff to achieve the goals of the "Triple Aim" of healthcare reform - to improve the experience of care, improve health outcomes, and decrease healthcare costs.
Serves as a Variety Care representative on community boards and task forces.
Embodies the strength of personal character. Places value on being an open and honest communicator who displays high moral and ethical conduct, integrity, adaptability, and sound judgment. Must be a leader in the department and community. Result-oriented problem solver who is responsible and accountable.
Performs other duties as assigned.