RN Care Manager - Y-Haven

About the role

This position is responsible for managing high-risk clients living in a residential substance use treatment center to promote effective education, self-management support, and timely healthcare delivery to achieve optimal quality and financial outcomes. Responsibilities include providing and coordinating direct client care to improve quality of care through the efficient use of resources, enhancing quality, and ensuring cost-effective outcomes. Acts as an advocate for the individual’s healthcare needs and coordinates care to minimize the fragmentation of healthcare delivery systems. This position is committed to the constant pursuit of excellence in improving the health status of the Y-Haven community.

Responsibilities

• Manages a caseload of residents with the most complex medical and psychiatric conditions, including assisting with medication management, routinely testing vital signs, blood sugar levels, oxygen levels, and maintaining communication with adjunct providers.
• Manages medication rooms and ensures compliance with CARF, Ohio MHAS, VA, and Ohio Medicaid standards.
• Facilitates specialized group counseling designed to provide education supporting chronic disease management, smoking cessation, and psychoeducation.
• Provides basic medical education to the rest of the Y-Haven team once per month.
• Collaborates with providers and practice staff in identifying appropriate clients for care management, utilizing established Care Management criteria.
• Performs initial and periodic assessments for the care-managed population, including physical and psychological assessments as appropriate. Prioritizes clients according to intensity, need, and required follow-up.
• Formulates and implements a care management plan addressing clients' identified healthcare needs by assessing client/family needs, issues, resources, and care goals.
• Establishes a mutually agreed-upon care management plan with the healthcare team and the client/family, containing specific, action-oriented self-management goals and interventions.
• Evaluates the effectiveness of the plan in meeting established care goals and revises the plan as needed. If certified in Advanced Practice with prescriptive authority, may make medication adjustments in collaboration with the Primary Care Provider.
• Monitors and evaluates client progress.
• Collaborates with the SUD Treatment team, primary care provider organizations, and community mental healthcare providers to revise the care management plan when changes occur. Initiates care conferences to discuss multidisciplinary team responsibilities, client progress, and new problems.
• Identifies and effectively utilizes community resources to meet the needs of clients/families. Facilitates client access to community medical resources as appropriate.
• Promotes client self-management and empowers clients/families to achieve maximum levels of wellness and independence.
• Performs follow-up calls for clients recently discharged from acute hospitalizations and considered high risk for readmission.
• Maintains EMR databases on the care-managed population and ensures accurate and timely documentation in the EMR.
• Reviews utilization and quality reports routinely to identify clients needing additional support.
• Performs all duties and responsibilities in accordance with the Nurse Practice Act and professional nursing guidelines.
• Performs medication reconciliation for all care transitions.
• Participates in regular team meetings, peer review activities, quality and organizational committees.
• Participates in the orientation of new personnel, precepts and mentors peers, and promotes collaborative teamwork.
• Abides by the organization's compliance program and requirements. Provides coverage across the organization as needed.
• Works collaboratively with the leadership team to improve and enhance care delivery through evaluation, development, and enhancement of policies and procedures.

Requirements

• RN required.
• Licensed to practice nursing in the State of Ohio.
• Proficiency in medication indications and side effects.
• Understanding of medical tests and requirements to provide patients with appropriate information.
• Minimum of 3 years of professional-level medical experience; experience in care coordination preferred.
• Experience working with an electronic medical record (EMR) required.
• Ability to work collaboratively with people of diverse cultures and lifestyles.
• Excellent organizational skills and ability to handle multiple priorities while remaining calm and professional.
• Ability to be self-motivating and work independently.
• Proficient to expert computer skills.
• Excellent written and oral communication skills.
• Problem-solving skills.

Benefits

• A free membership to your local YMCA and discounts on YMCA programs, including childcare (part-time positions do not receive a discount on childcare).
• Additional employee discounts at many places in and around town.
• Comprehensive Benefits Plan including Health, Dental, Vision, and Employee Assistance Plan.
• Retirement plan with 8% contribution paid by the YMCA of Greater Cleveland.
• Paid vacation.