RN, Care Manager

VARIETY CARE INC•Oklahoma City, OK

About The Position

The RN Care Manager is a registered nurse who directly supports Variety Care’s highest-risk patients, with a primary focus on at-risk populations. Working with other members of the healthcare team, the RN organizes, coordinates, and provides care management services for patients at risk of health deterioration, poor outcomes, or avoidable emergency care utilization. The role also leads care management for a designated subset of patients and supports coordinated, team-based care across internal and external services. The position is located in Reno (VC), Oklahoma City, Oklahoma, is assigned to the Population Health department, and works a day shift. It is non-exempt and reports to the Population Health Manager. The role supports Variety Care’s Patient Centered Medical Home accreditation and its commitment to safe, effective, patient-centered, timely, efficient, and equitable care. It also supports the healthcare reform “Triple Aim” of improving care experience and health outcomes while reducing costs.

Requirements

Active RN license in good standing in the state of Oklahoma.
Excellent oral and written communication skills.
Must be able to lift 25 pounds.

Nice To Haves

Two years of care management experience in a community-based setting.
Bachelor of Science degree in Nursing.
Bilingual in English and Spanish.

Responsibilities

Manage Variety Care’s high-risk patient population.
Conduct comprehensive assessments 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 emergency room utilization.
Reconcile patient medication lists accurately and routinely.
Coordinate information flows with providers and optimize the office-based care team to send, receive, and triage information.
Use behavioral strategies, including Bridges out of Poverty, Crucial Conversations, and Teach-Back techniques.
Promote self-management goals that help patients adopt healthy behaviors and improve self-care.
Optimize use of Variety Care services, including Behavioral Health, Social Services, Community Health Worker, Enrollment Services, Nutrition, Pharmacy, Optical, and Dental.
Lead the care management team for a subset of patients designated by the Population Health Manager, in coordination with the Director of Clinical Services.
Assist Social Services staff and Community Health Workers in prioritizing and intervening effectively to maintain patients’ medical stability and improve quality of life and health outcomes.
Coordinate and verify that services, equipment, and necessary supplies are in place.
Participate in regular case staffing meetings and reviews.
Follow up with patients within 24 hours of inpatient discharge and within 48 hours of notification of an emergency department visit.
Partner with external case management programs to coordinate care.
Evaluate and document patient progress and risk status on an ongoing basis.
Communicate and collaborate with internal care teams.
Accurately document and monitor care coordination activities in the electronic health record.
Proactively support Variety Care initiatives related to care coordination and participate in 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 staff and as a representative of Variety Care on community boards and task forces.
Adhere to Variety Care policies and procedures and support its Patient Centered Medical Home accreditation and care commitments.
Provide leadership and work with staff to advance the healthcare reform Triple Aim.
Demonstrate integrity, adaptability, sound judgment, accountability, and ethical conduct; communicate openly and honestly and serve as a leader in the department and community.
Perform other duties as assigned.