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Title

Care Manager Registered Nurse 

Category Clinical Services  
Description

Position Purpose:

The RN Care Manager will be responsible for evaluating patient risk, identifying gaps in care, coordinating in-bound/out-bound referrals/authorizations and care transitions, and developing and updating an integrated care plan based on a comprehensive assessment of each patient, while consulting with the patient, their family/caregiver(s)/legal guardian(s), primary care provider (PCP), specialty providers, and behavioral health and/or IDD providers. This is a vital role in an integrated care model that will promote optimal health outcomes, improve quality of care, and reduce overall cost of care for the populations served.

Essential Job Functions:

  • Evaluates assigned patients and information from the PCP, behavioral health provider, and other specialists and writes an assessment (including risk assessment) and an integrated care plan.
  • Implements the care plan and coordinates authorizations/arranges for delivery of covered services consistent with the care plan.
  • Conducts ongoing communication and collaboration with patients/clients, family/caregivers, legal/designated representatives, as well as with the PCP, care team members, and other significant health care providers or community services/supports.
  • Tracks and ensures provision of services across all health care settings eliminating barriers and following up to ensure they are timely, appropriate, and in accordance with the care plan.
  • Provides coordination of care transitions, including transition planning from hospitals, treatment facilities or nursing homes, subacute, rehab, as well as internal care transitions within the organization.
  • Facilitates appropriate establishment of Advance Care Planning and assuring appropriate administration of the patient's/client's Health Care Proxy.
  • Reviews changes in patients'/clients' medical status, identifying follow up issues for discussion and collaboration with the care team.
  • Monitors chronic conditions monthly or more frequently as indicated and creates an evidenced-based comprehensive action plan for each patient.
  • Delivers clear communication among care team members by ensuring consensus and updates regarding patient/client care plans.
  • Actively participates in staff meetings, case conferences, and other meetings as appropriate.
  • Promotes and role models collaborative practice relationships with all health care professionals.
  • Serves as primary contact with patient's PCP or specialist physicians as well as other significant health care providers.
  • Monitors medication adherence and gaps in care and/or support.
  • Counsels patients on their medical condition and provides education/coaching on self-management or care giving by family members.
  • Recognizes the role that cultural diversity of patients and their families, employees, health care staff, and community members plays in achieving productive and positive relationships.
  • Conducts CM level driven outreach visits/calls to each member to check on their progress status in relationship to optimal clinical outcomes and patient/client experience.
  • Updates patients' medical records / care plans / Care Team recommendations to support optimal health.
  • Monitors and documents ongoing progress towards established goals.
  • Participate in Quality Assurance and Improvement activities.
  • Works in partnership with leadership, providers, and support staff to further ESUCP's mission and vision and accomplish common goals and objectives.
  • Other duties as assigned.
 
Position Requirements

Required Education/Experience:

Associate's or Bachelor's Degree in Nursing.

Current Licensure as a Registered Nurse in the State of North Carolina.

Minimum of five (5) years direct patient care experience and two (2) or more years of care management experience required.

Minimum of one (1) year as a clinical nurse manager with performance improvement responsibilities is desirable.

Knowledge, Skills and Abilities:

Demonstrated knowledge of trauma-informed care and providing culturally competent care.

Experience with health coaching/education and developing care plans.

Previous experience in behavioral health, care management, outcomes management, change management, and/or quality management is preferred.

Good interpersonal and communication skills, including ability to deal with people effectively under stress. Must communicate warmth and be able to put people at ease.

Knowledge of Medicare and Medicaid regulations and standards, HEDIS/quality measures, and value-based payment methodologies.

Computer skills: MS Office (Word, Excel, Outlook, PowerPoint), EHR and/or Care Management Software.

 
Full-Time/Part-Time Full-Time  
Shift Days  
Position Case Manager Registered Nurse  
Division Clinical  
Exempt/Non-Exempt Non-Exempt  
Location Clinical Raleigh  
About the Organization Easterseals UCP has been part of the fabric of North Carolina and Virginia for 75 years. We started in counties all over NC and VA filling gaps and addressing the needs of children and adults with disabilities. Our legacy organizations Easterseals NC, United Cerebral Palsy NC, and Easterseals Virginia joined forces as Easterseals UCP to intentionally work side-by-side with more than 20,000 individuals and their families, providing the broad network of services and support they need to achieve better days. Today we are affiliated with both Easterseals, Inc. and United Cerebral Palsy Inc.

Our mission is to create opportunities, promote individual choice, and change the lives of children and adults with disabilities by maximizing their individual potential to live, learn, work and play in their communities.
 
EOE Statement We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.  
SuperVFlg None Specified 

HoursPerWk None Specified 

This position is currently accepting applications.

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