RN Care Manager

Job Summary

The RN Care Manager addresses the needs of the population served by assessing, planning, implementing, coordinating, monitoring, and evaluating the options and services required and uses communication and available resources to promote quality, cost-effective health outcomes. This position works within the Registered Nurse scope of practice, and in concert with the Primary Care Provider, patient, caregivers, family members, other members of the Care Management Team and the community to coordinate a full continuum of health care services considering the holistic needs of the member, inclusive of unique social and cultural dynamics.

Responsibilities

• Provide effective Care Management services based on case management standards of practice to enrolled populations
• Complete comprehensive assessments considering the total individual, inclusive of medical, biopsychosocial, behavioral, spiritual and cultural needs to enrolled population, throughout the continuum of care
• Develop, review, and evaluate the member care plan in partnership with the member, caregiver/family members, providers, and Care Management team members, as applicable
• Work with patients to identify behavioral, social, cultural, and environmental strengths and challenges as it relates to his/her diagnosis, treatment, and access to care
• Occasional need to triage patients
• Identify and address barriers that impede health outcomes
• Implement Care Management interventions per the patient’s care plan
• Work in conjunction with patient to formulate, develop, and implement patient-centered plans using therapeutic skills and techniques such as trauma-informed care, motivational interviewing, strengths-based, and solution-focused modalities
• Provide education to patient/family about clinical diagnosis, medications, available resources, prevention, and risk factors to achieve optimal self-management
• Utilize therapeutic skills and techniques to help patients achieve healing, growth, health, and wellness
• Monitor quality and effectiveness of interventions to the enrolled populations by setting patient-centered SMART goals in collaboration with the patients/families
• Process referrals to members of the patient engagement team (social work, behavioral health, community resource coordinators) and/or clinical team (pharmacy, pharmacy technician, patient coordinator) appropriately, accurately and timely according to established workflows
• Serve as a liaison among the patient/family, community services, primary providers, specialists, and other care team members to coordinate services without duplication
• Work collaboratively with multi-disciplinary team members to facilitate achievement of desired treatment outcomes
• Maintain appropriate member documentation in the Care Management documentation platform, in accordance with organizational policies and procedures
• Engage and maintain collaborative relationships with community provider agencies that promote quality care and cost-effective health care utilization
• Adhere to CCHC privacy and security policies to ensure that patient and network data are properly safeguarded
• Absorb department guidelines, company policies, and HIPAA regulations
• Attend departmental and corporate meetings, local and regional training's, or other events as required
• Willingly performs other duties as assigned
• Works under the direct supervision of the Director of Nursing

Qualifications

• Licensed and credentialed Registered Nurse from an accredited school of Nursing with unrestricted licensure
• Bilingual preferred, but not required
• 3-5 years’ experience in clinical or community resource settings with; care coordination and/or case management experience
• Evidence of essential leadership, education, counseling skills, and strong interpersonal skills; ability to work with colleagues across sites
• Proficiency in communication technologies (email, cell phone, etc.)
• Highly organized with ability to keep accurate notes and records
• Experience with health IT systems and reports is desirable
• Local knowledge about and connections to community health care and social welfare resources is desirable
• Bilingual in English and Spanish is preferred but not required
• Current BLS certification (or earned within 90 days of hire)
• Able to travel to other clinical sites when needed

Special Skill Requirements

• Core values consistent with a patient- and family-centered approach to care
• Demonstrates professional, appropriate, effective, and tactful communication skills, including written, verbal and nonverbal
• Demonstrates a positive attitude and respectful, professional customer service
• Acknowledges patient’s rights on confidentiality issues, maintains patient confidentiality at all times, and follows HIPAA guidelines and regulations
• Proactively acts as patient advocate, responding with empathy and respect to resolve patient and family concerns, and recognizes opportunities for improvement to meeting patient concerns
• Proactively continues to educate self on providing quality care and improving professional skills
• Must be able to interact with individuals of all cultures and levels of authority
• Must be able to function as part of a team

Benefits

• Medical Insurance
• Dental Insurance
• Vision Insurance
• Short Term & Long Term Disability
• Life Insurance
• 401K Retirement Plan w/ discretionary match
• Paid Time Off (PTO)
• Holiday Pay
• Employee Assistance Program (EAP)

About Us

Charlotte Community Health Clinic, Inc. is an Equal Opportunity Employer. We do not discriminate in any aspect of employment with regard to age, race, sex, national origin, disability, color, marital status, veteran’s status, or religion. We are committed to serving the underserved and offering high-quality medical, dental, and behavioral health services for children and adults. We accept most major health insurance plans, as well as Medicaid and Medicare. For more information, visit our website.