RN Care Manager (Rocky Mount)

North Carolina Community Health Center Association•Rocky Mount, NC

About The Position

The RN Care Manager serves as a liaison between the central CMHN clinical team and practice-based clinical teams at member health centers. The role prioritizes and assesses patients, engages them around their highest-priority needs, and coordinates care to support quality, cost-effective outcomes. Core functions include planning interventions, coordinating with internal and external care team members, monitoring progress toward patient and population goals, and evaluating the effectiveness of approaches. Particular attention is given to transitions of care. The Care Manager must be a North Carolina-licensed Registered Nurse and work within the RN scope of practice alongside the Care Management Team, primary care provider, patient and family, and community partners to coordinate a continuum of services aligned with the patient's holistic needs. The role may supervise and manage care coordinators assigned to the team. The position may require travel to health centers and may be performed remotely as defined by the health center or NCCHCA policy.

Requirements

Associate degree or higher from an accredited School of Nursing.
Licensed as a Registered Nurse (RN) in North Carolina.
At least three years of experience providing care management, case management, or care coordination to a safety-net population.
Excellent written and oral communication skills.
Proficiency with electronic medical records and Microsoft Outlook, Word, Excel, PowerPoint, and email.
Ability to communicate clearly and succinctly.
Dependability and effective time management; efficiency and organization.
Ability to produce accurate work and perform multiple tasks proficiently and on time.
Good supervisory and management skills.
Operational automobile, current active North Carolina driver's license, and auto insurance.
Ability to meet the physical demands of the job, including standing, sitting, talking, hearing, using a computer and telephone keyboard, reaching, stooping, kneeling, light to moderate lifting, and tolerating travel-related stress.
Regular, predictable attendance.

Nice To Haves

Certified Case Manager (CCM).
Experience or knowledge related to Medicaid populations, FQHCs, HEDIS, care gap closure, telephonic care management, population health, SDOH assessments, and chronic care management.

Responsibilities

Provide oversight of Care Management services and activities in accordance with standards of practice for enrolled populations.
Develop, review, and complete comprehensive, patient-centered assessments that consider medical, biopsychosocial, behavioral, spiritual, and cultural needs throughout the continuum of care.
Work with patients and caregivers to identify and address behavioral, social, cultural, and environmental strengths and barriers related to diagnosis, treatment, and access to care.
Implement Care Management interventions, set goals, and develop plans of care based on transitional care discharge plans or instructions, comprehensive assessments, and patient goals.
Implement patient-centered plans using therapeutic approaches such as motivational interviewing, strengths-based, and solution-focused modalities.
Educate patients and families about diagnoses, medications, available resources, prevention, and risk factors to support self-management.
Monitor intervention quality and effectiveness by setting patient-centered SMART goals with patients and families.
Delegate tasks and referrals to Care Management Team members appropriately, accurately, and timely according to established workflows.
Advocate and serve as a liaison among patients and families, community services, primary providers, specialists, and other care team members.
Collaborate with multidisciplinary team members to facilitate desired health outcomes.
Maintain timely and appropriate documentation in the Care Management documentation platform in accordance with organizational policies and procedures.
Build and maintain collaborative relationships with community provider agencies to promote quality care and cost-effective health care utilization.
Follow privacy, security, department, company, and HIPAA policies and guidelines.
Attend departmental and corporate meetings, local and regional training, and other required events.
Visit health centers as needed to coordinate with clinic-based care teams and/or patients and families.
Support organizational goals and performance improvement targets for initiatives, programs, and standards of care.
Review care management productivity and clinical performance data to assess priorities and determine appropriate interventions.
Ensure standardized plans of care, assessment and care plan standards, team development, and organizational and team goals are met.
Manage and supervise team members to ensure work is completed timely and accurately.
Perform other duties as assigned.
Supervise Care Coordinators assigned to the Care Management Team.