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Title

RN Care Manager  

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), medical specialists, and behavioral health and/or IDD specialists. This is a vital role in an integrated care model that will promote optimal health outcomes, improve quality of care, and reduce the overall cost of care for the populations served.

Essential Job Functions:

  • You will work in a radically different model of healthcare.
  • Expect collaboration, shared-decision making, and partnership across clinical and non-clinical care team members.
  • In addition to supporting your clients in the community, you will be asked to support clinical operations in the clinic on a rotating basis by having an in-person presence and working with providers as needed (onsite requirement beginning in early 2022).
  • Co-manage a population living with complex medical and behavioral health conditions.
  • Collaborate on a panel of clients assigned to your care team to develop comprehensive care plans and provide nursing clinical support, including transitional care, health maintenance, medication reconciliation & administration, chronic disease management, and treatment of co-occurring psychiatric disorders.
  • Implement the care plan and coordinate authorizations/arrange for delivery of covered services consistent with the care plan.
  • Track and ensure the 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.
  • Foster lasting and trusting relationships to assist clients in achieving goals, identifying new needs, and coordinating care.
  • Recognize the role that cultural diversity plays in achieving productive and positive relationships.
  • Your work will take you into the community. You will meet with clients in their homes, in their communities, at the point of hospital discharge, and within the healthcare system. These visits can be done individually or as co-visits with one of your care team members (i.e. Community Health Partners, Behavioral Health and/or IDD Specialists, Nurse Practitioners, and/or Physician Assistants).
  • May conduct several home visits on a given day, including scheduled and unscheduled episodic urgent member needs.
  • Provide ongoing clinical support to your panel of clients in partnership with your interdisciplinary care team, prioritizing member visits based on their health needs.
  • Assess in-home safety and risks and implement evidence-based interventions and protocols for complex chronic conditions.
  • Assist clients with medication reconciliation, medication administration & medication compliance.
  • Facilitate the appropriate establishment of Advance Care Planning and assuring appropriate administration of the patient's/client's Health Care Proxy.
  • Review changes in patients'/clients' medical status, identifying follow-up issues for discussion and collaboration with the care team.
  • Monitor chronic conditions monthly or more frequently as indicated and creates an evidenced-based comprehensive action plan for each patient.
  • Deliver clear communication among care team members by ensuring consensus and updates regarding comprehensive care plans.
  • Actively participate in daily huddles, case conferences, and other meetings as appropriate.
  • Monitor medication adherence and gaps in care and/or support.
  • Counsel patients on their medical condition and provides education/coaching on self-management or caregiving by family members.
  • Conduct 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.
  • Update patients' medical records/care plans / Care Team recommendations to support optimal health.
  • Monitor and document ongoing progress towards established goals.
  • Participate in Quality Assurance and Improvement activities.
  • Work in partnership with leadership, providers, and support staff to continuously improve our integrated care model and delivery of services.

You will ensure clients on your panel:

  • Meet all appropriate preventive care, behavioral health, and chronic disease quality measures
  • Have accurate, up-to-date medication lists in the EMR and are following prescriber's orders.
  • Have accurate, up-to-date comprehensive care plans (CCPs) in the EMR
  • Receive appropriate care following ED visits and acute admissions

Knowledge, Skills, and Abilities:

  • Demonstrated knowledge of trauma-informed care and providing culturally competent care.
  • Ability to utilize critical thinking skills and excellent communication skills to manage complex clinical issues leveraging assessment skills and protocols.
  • Independent self-starter, a leader, and a strategic thinker who is excited about the big picture of whole community health, and the ongoing evaluation and iteration of our care model.
  • Demonstrated proficiency, prior experience, and/or willingness to train in clinical nursing skills such as wound assessment and care, blood draws, assessment, and care plan reinforcement for common chronic conditions such as diabetes, hypertension, CHF, depression.
  • Experience with health coaching/education and developing care plans; demonstrated ability to affect change, and have been effective in helping a client or patient adopt new habits, or change behaviors.
  • Previous experience in behavioral health, care management, outcomes management, change management, and/or quality management is preferred.
  • Computer skills: MS Office (Word, Excel, Outlook, PowerPoint), EHR, and/or Care Management Software.

Nice to Have, But Not Required:
3+ years of experience providing clinical services to individuals with co-occurring chronic medical and behavioral health conditions.

Bachelor's degree preferred.

Multilingual

 
Position Requirements

Requirements:

  • Associate or Bachelor Degree in Nursing.
  • 3 years of clinical experience.
  • Active, unrestricted Registered Nurse license in the State of North Carolina.
  • Your work may take you outside of normal business hours as urgent client needs arise.
    Must have an unrestricted driver's license and vehicle for daily use.
 
Full-Time/Part-Time Full-Time  
Shift -not applicable-  
Position RN Care Manager  
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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