RN Care Manager - Care N Care Insurance Company of North Carolina

Job Summary

Under the direction of the Director of Care Management, the RN Care Manager is responsible for managing high risk, chronic illness members to promote effective education, self-management support, and timely healthcare delivery to achieve optimal quality and financial outcomes. The RN Care Manager will formulate and implement a care management plan that addresses the members identified needs by assessing issues, resources, and care goals. The RN Care Manager will advocate for the member and support the member in navigating the health care system. Additionally, the RN Care Manager will collaborate with the interdisciplinary team and members PCP / Health Care Team to identify and support achievement of the members short term and long-term health goals. HTA’s Care Management model is to provide longitudinal care management for identified members. A key goal of the RN Care Manager within the longitudinal care management framework is to manage the post-acute care of identified members to avoid and limit poor health outcomes, frequent emergency room visits, and hospital readmissions. Based on the RN’s work experience in nursing and knowledge of the health care system, aims are to provide education and resources to members to ultimately reduce preventable emergency room visits, hospitalizations, and re-admissions. 

Essential Job Functions:

1. Collaborates with providers and practice staff in identifying appropriate members for care management, utilizing established Care Management criteria.

2. Performs initial and periodic holistic assessments for identified care managed population. This includes physical and psychosocial concerns for members as appropriate. The assessment includes a systematic and pertinent collection of data about the health status of the member. Prioritizes members according to intensity, need, and required follow up.

3. Formulates and implements a care management plan that addresses the member’s identified needs by assessing the member/family needs, issues, resources, and care goals; determining the choices available to individual members; and educating the patient/family on the choices available to meet their goals.

4. Establishes a care management plan that is mutually agreed upon by the health care team and the member/family. Plans specific mutual self-management goals and objectives and interventions with the members that are action-oriented.

5. Evaluates the effectiveness of the care plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues, and goals. Monitors and evaluates the progress of the member at prescribed minimal intervals.

6. Collaborates with the healthcare team to revise the care management plan when changes occur. Initiates/participates in care conferences to discuss multidisciplinary team responsibilities, member progress, new problems, etc.

7. Identifies and effectively utilizes community resources to meet the needs of members/families. Facilitates member access to community resources as appropriate and/or refers to Social Work. 

8. Promotes member self-management and empowers members/families to achieve maximum levels of wellness and independence. Interacts professionally with member/family and involves member/family in the formation of plan of care.

9. Performs follow up calls for members recently discharged from acute hospitalizations, with particularly emphasis on those members who are high risk for readmission.

10. Collaborates with providers and other healthcare team members to include inpatient facilities, outpatient providers, and Utilization Management department, to initiate transitions of care and facilitate care across the healthcare continuum and optimize clinical and financial outcomes.

11. Determines and completes appropriate referrals. Serves as a liaison to providers, members, and families for coordination of services.

12. Maintains accurate and timely documentation. Ensures documentation meets current standards and polices.

13. Strives to meet established standard for productivity.

14. Participates in regular team meetings and peer review activities. Participates in departmental and organizational committees, as applicable. Assists/supports in the orientation of new personnel. Promotes collaborative teamwork.

15. Meets with the care management team leader (Director of Care Management) and the care management team on a regular basis to provide member updates, identify issues, and develop strategies for resolution.

16. Performs all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with basic principles and guidelines of professional nursing.

17.  Maintains appropriate professional boundaries with members, families, coworkers, and community providers.

18. Maintains a working knowledge of, and adheres to, applicable federal and state regulations including, but not limited to, laws related to patient confidentiality, release of information, and HIPAA.

19. Interacts harmoniously and effectively with others, focusing upon the attainment of organizational goals and objectives through a commitment to teamwork.

20. Conforms to acceptable attendance and punctuality standards as expressed in the HTA Employee Handbook.

21. Abides by the organization’s compliance program and requirements.

22. Current on all required training for current year. 

Essential Job Duties and Requirements:

Coordinates care provided to a community-based member population of various risk stratification levels as follows:

• Ability to effectively engage members by telephone to conduct thorough screening, physical and psychosocial assessments on community-based caseload of members in a timely manner and within established guidelines.
• Consistently collaborates with member and family, physicians, and other health care team members to identify physical and psychosocial issues or barriers that affect health condition management.
• Implements a comprehensive, patient-centered plan of care to proactively manage identified issues and effect positive health outcomes.
• Prioritizes caseload to balance member and departmental needs.
• Acts as a member advocate and coordination link with other health care providers and community resources to positively impact outcomes.
• Advocates for the member to overcome barriers and resolve benefit issues. Assist members to navigate healthcare system and insurance benefits.
• Facilitates transition of care across by the continuum by identifying barriers to discharge and proactively working with members, providers, and vendors to address identified needs and facilitate appropriate transfers the next safest level of care for members.
• Meet with members/providers in person at inpatient hospital, emergency room, SNF, and/or provider offices as needed to facilitate transition of care along with continuum. 

Formulates and implements a care management plan addressing the member’s identified needs:

• Thoroughly assesses each member’s eligibility for needed resources.
• Risk stratifies members and identifies barriers or gaps in treatment and refers to the appropriate team member to address the need as indicated to holistic care positive outcomes.
• Stays abreast of community resources and refers the Member for services and assistance when appropriate.
• Willingly collaborates with health care team members to formulate an individualized care plan and goals that best meet the needs of the family/member.
• Utilizes motivational interviewing techniques to engage members in goal setting.
• Updates individualized member care plan to articulate current short-term and long-term goals, as well as when these goals are met and/or revised.
• Consistently communicates with the health care team members to ensure patient care needs are addressed in a timely manner.
• Communicates care coordination and key elements to provider per department requirements.

Monitors members adherence to treatment plans as follows:

• Consistently monitors adherence to the member’s treatment plan and relays issues to appropriate care providers promptly and effectively.
• Proactively identifies barriers to adherence and acts promptly to revise the treatment plan to improve member adherence and outcomes.
• Takes prompt action when issues involving the appropriate and cost-effective utilization of resources are identified, collaborating with appropriate health care team members.
• Confers with the members/families, physicians and other care providers, and insurance carriers in the role of patient advocate, as needed to resolve benefit issues and secure necessary services.

Provides documentation of care management activities as follows:

• Consistently documents all care management activities in the Care Enrollment Record(s) and/or software applications using the established format in a timely and accurate manner per department requirements.
• Promptly sends reports and communications to physicians and other providers as per department requirements and as needed to relay pertinent findings.
• Actively participates in program quality improvement activities.

Provides Health education as follows:

• Considers teaching methods utilized for members/families based on individual needs/differences.
• Utilizes a variety of approaches to effectively educate members/families as well as other members of the health care team regarding community resources, health care benefits, and insurance and managed care issues.
• Follows-up to evaluate the effectiveness of education provided and documents appropriately.
• Participates in multidisciplinary patient care conferences as needed.
• Consistently and accurately documents health education activities in the documentation system per department requirements.
• Appropriately updates departmental leadership with necessary in information impacting delivery of member services or ability to deliver health education.
• Assists in program development and group education.
• Supports training of new staff members.

Education and Experience

Education:

• Associate Degree in Nursing

Required Experience:

• Five years nursing related care experience and/ or home care experience combined.

Preferred Experience:

• BSN or Advanced Degree in Nursing
• Case Management Certification desirable.
• Case Management, Care Management, Telephonic Case Management, and/or Disease Management experience

Other Requirements:

• Registered Nurse licensed in North Carolina or a Compact state.
• Current NC RN licensure in good Standing
• Valid NC driver’s license
• Annual Flu Vaccine

Knowledge, Skills and Abilities:

Required Competencies: 

• Knowledge of care management concept along the continuum. 
• Knowledge of Medicare Benefits
• Experience and ability to use Microsoft Office products and word-processing software on a daily basis. 
• Must be able to drive to local healthcare facilities to meet with members/providers as needed
• Excellent written, verbal and listening communication abilities. Communicates appropriately and clearly to members, coworkers, and providers.
• Ability to manage conflict, stress and multiple simultaneous work demands in an effective and professional manner.
• Ability to successfully articulate the process of attaining goals and outcomes of care management
• Ability to apply clinical knowledge and experience in a care management role
• Ability to engage and collaborate with the member and significant others in the care management process.
• Ability to care manage diverse populations without applying one’s own personal values
• Ability to work with minimal supervision within nursing scope of practice
• Ability to think critically and analytically and work with minimal supervision.
• Ability to evaluate and appropriately respond to verbal and non-verbal communication from patients in diverse stages of development
• Ability to use good judgment to protect personal safety while performing duties

Preferred Competencies:

• Advanced clinical knowledge.
• Skills related to physical assessment, wound care, blood pressure monitoring, CBG checks, and Foley Cath care. Clinical knowledge and ability to educate clients of all ages about the following core disease management issues: Diabetes, Hypertension, Hyperlipidemia, CAD, Asthma, COPD, and renal disease required. (This is not intended to be an inclusive list of all conditions.)

Physical Requirements:

• Exerting up to 10 pounds of force occasionally (up to 1/3 of the time) and/or a negligible amount of force frequently (1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time.
• Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.

Benefits from Day One: 

• Medical, Dental, and Vision Coverage
• 401(k) Retirement Plan with Company Match
• Paid Time Off (PTO) and Volunteer Time Off (VTO)
• Paid Company Holidays
• Health Savings Account (HSA) and Flexible Spending Account (FSA) Options
• Long-Term and Short-Term Disability Coverage
• Employee Assistance Program (EAP) for Personal and Professional Support
• Tuition Assistance for Continued Education
• Pet Insurance for Your Furry Family Members
• Ongoing Professional Development and Training Opportunities
• And an array of additional benefits designed with you in mind.