Nurse Case Manager

About the role

The OU Sooner Health Access Network (HAN), housed within the Department of Medical Informatics, is dedicated to advancing access to affordable, high-quality, person-centered care across Oklahoma. Partnering with primary care practices statewide, OU Sooner HAN delivers comprehensive support through innovative care management, quality improvement consulting, and targeted education and training.

Responsibilities

• Collaborate with members to create a member’s plan of care, including identifying goals, barriers and strengths.
• Clinical assessment of member’s medical and behavioral health, and social determinants of health.
• Assess barriers to achieving goals including health status, functional abilities, behavioral health, social issues, environmental and safety concerns, caregiver stability, self-management skills, and life care planning.
• Assess member’s strengths and confidence in achieving goals.
• Conduct ongoing medication reconciliations including assessing for barriers.
• Monitor and evaluate plans including progress toward goals, health status, medication reconciliation and member experience.
• Review and interpret medical test results.
• Evaluate effectiveness of medical treatments.
• Recognize and communicate signs and symptoms of change in member’s health status.
• Depending on the care management pathway followed, contact is provided daily to at least monthly to members: home visits to evaluate home environments and family relationships, and to provide support and self-management coaching. Medical and psycho-social appointments to facilitate collaboration. Telephone calls. Hospital visits. Secure email.
• Understands and is able to apply the concepts of disease management and risk management in service planning.
• Utilize critical thinking to assess alternative approaches to problems and/or decisions.
• Review and interpret therapist reports and psychiatry reports.
• Recognize and communicate with team any signs and symptoms of changing mental health needs.
• Crisis management.
• Link member and caregiver to supportive community services as needed and follow up to confirm contact.
• Facilitate access, communication and collaboration between member and all providers.
• Provide and coordinate transition services across all settings of care.
• Communicate care plan to all providers in all settings of care (Emergency Department, hospital, rehabilitation facility, home care, nursing home and specialists).
• Ensure member, caregivers and providers receive timely information for treatment decisions across all settings.
• Coordinate/verify services, equipment and supplies are in place.
• Reconcile medications at every contact.
• Routinely maintain records to document and monitor the care management activities in the management information system.
• Participate in regular interdisciplinary case staffing meetings and reviews.
• Communicate and collaborate with other providers (e.g., specialists, respiratory therapists, nutritionists, physical therapists, home health providers, care managers, social workers, etc.) by optimizing the office-based care team to send, receive, and triage information flows among the providers.
• Communicate with, educate and advise members and family, helping them to understand conditions and treatments.
• Participate in Quality Improvement activities.
• Monitor identified performance measures and deliverables and provide regular progress reports - Report submission will be determined as performance measures and deliverables are identified.
• Follow and practice defined evidence-based protocols in all care management related activities and responsibilities.
• Conduct assessments and monitoring within prescribed timelines.

Qualifications

• Bachelor's Degree in Nursing.
• 12 months of professional nursing experience.
• Equivalent/Substitution: Will accept an Associate's degree in Nursing and 24 months of professional nursing experience in lieu of the Bachelor's Degree for a total of 36 months professional nursing experience.
• State of Oklahoma Registered Nurse Certification.

Skills

• Demonstrate and apply principles of person-centered, strength-based philosophy, motivational interviewing, shared decision making, coaching and adult learning.
• Demonstrate a sensitivity and responsiveness to a variety of cultural values and beliefs and social determinants of health.
• Practice trauma informed approach.
• Community Representative.

Benefits

• Eligible: True

Pay

Pay Range: Commensurate based on education and experience

Schedule

Work Schedule: Monday – Friday, 8:00 a.m. to 5:00 p.m.

Travel

Not required