Care Manager - Rn

Location: 100% Remote: This position is 100% remote, with the possibility of being hybrid.

Most of the positions at YCCO are hybrid, meaning they have the flexibility to work both remotely and/or in-person.

Department: Heath Plan Operations FLSA Status: Exempt

Reports To: Care Management Manager Physical Strength: Light (L)

Learn more about Yamhill Community Care: click here

Summary

Under the direction of the Care Management Manager and the Health Plan Operations Sr. Director, the Care Manager - RN (CM) performs outlined Care Management duties for priority population members, members with mental health issues, and chronically ill Medicaid members with diagnoses that include chronic kidney disease, diabetes, chronic obstructive pulmonary disease (COPD), and cardiovascular disease. The CM works in collaboration and continuous partnership with the members, their families / caregivers, clinical support staff, clinic providers, and community resources in a team approach to improve member outcomes and increase our patients’ ability to self-manage.

Essential Duties

• Builds and maintains relationships with YCCO members, providers, and community partners to ensure care needs are identified and positive outcomes are met.
• Provides day-to-day Care Management and Care Coordination services for Yamhill Community Care (YCCO) members.
• Collaborates with staff, providers, and community partners to establish and make available resources and support that meets the needs of YCCO members.

Job Duties

• Utilizes nursing processes with a focus on best practice for interventions and outcomes with care plan routinely updated.
• Provides care in the context of the identity, culture, health status, and health needs of the individual. Demonstrates teamwork and communication to include early collaboration when issues arise utilizing team-based problem-solving and planning.
• Applies Population Health Management tools to maximize benefits of chronic disease management prevention and wellness campaigns.
• Supports member confidence to deal with medical and emotional management of their conditions by offering self-management supports including baseline comprehensive needs assessment (physical and social determinants of health) reflecting patient values, preferences, and goals.
• Works closely with members and clinic providers to manage calls involving symptom control and medication management, provides member education etc., and facilitates cross-setting communication including care plan transmission between settings with changes and updates.
• Educates and engages members and families using the teach back method for information on care interventions. Patients and families prepared with “Ask Me Three” questions.
• Makes appropriate referrals both internally and externally to appropriate departments / resources.
• Advocates for members and families where member concerns are heard, access to providers is facilitated, community resources are made available, and medications are managed.
• Reviews Care Management referrals received from members, providers, community partners, and the plan.
• Applies patient-centered care planning techniques and motivation interviewing to elicit patient-focused goal and priorities to develop care plans and transcend barriers.

Related Program Duties

• Transitions of Care: Robust Care management for 30 days post-inpatient care to include post-discharge phone calls, medication reconciliation, facilitating follow-up appointments, and symptom management.
• Chronic Disease Management: Collaborates with members and providers to manage and control chronic diseases to include member education, Primary Care Provider (PCP) and specialty referrals and facilitation of appointments, and symptom management through the development of care plans.
• Pediatric Care Management: Assists families and children with special healthcare needs with a comprehensive suite of services and activities to help members develop and thrive.
• Intensive Care Management: Collaborates with priority population members, providers, and care team members to manage complex health conditions, mental health issues and other social determined factors to support the member through member education, PCP and specialty referrals, facilitation of appointments, symptom management through the development of care plans to include a more robust, intensive care management program.

Essential Department & Organizational Functions

• Works collaboratively in a team and matrixed (cross-department) environment with a spirit of cooperation.
• Participates in the preparation and submission of regulatory and contract required deliverables.
• Meets deadlines for completion of assigned responsibilities and projects.
• Proposes and implements process improvements.
• Respectfully takes direction from Supervisor.
• Maintains agreed upon work schedule with punctual, regular, and predictable attendance.
• Meets identified goals that contribute to departmental goals.
• Other duties as assigned.
• Demonstrates cooperation and teamwork using a professional and respectful demeanor.
• Works closely with other YCCO departments, including Health Plan Operations and Compliance to assist with audits; including the External Quality Review (EQR), as needed.
• Provides cross-training on specific job responsibilities.
• Works to cultivate and develop inclusive and equitable services, and working relationships with diverse groups of employees, community partners, and community members.

Knowledge, Skills, & Abilities

• Excellent organizational skills including ability to handle multiple priorities and demands simultaneously in a dynamic work environment while maintaining high attention to detail and accuracy.
• Must be highly motivated, results oriented, with strong organizational skills with the ability to multi-task with time management skills. Focused customer service skills and excellent problem-solving skills.
• Bilingual Spanish / English strongly preferred.
• Ability to remain flexible, positive, and adaptable. Ability to work across the YCCO region and to work remotely, as needed.
• Ability to communicate both professionally and effectively in all forms of communication.
• Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook.
• Ability to work independently, use sound judgment, anticipate next steps and be proactive as part of a diverse team within a Matrix or shared resources across departments work model.
• Strong working knowledge of chronic disease states and basic medical management of these states.
• Ability to work in an environment with diverse individuals and groups.

Supervisory Responsibilities

This position has no supervisory responsibility.

Qualifications

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

Required

Education & Experience

• Minimum 1-2 years' clinical nursing experience in an area such as medical/surgical, skilled nursing, or behavior health.
• Graduate from accredited school of nursing.
• Minimum 1-3 years’ work experience in healthcare setting including experience with care management, disease management, and/or quality improvement.

Or

• Any combination of education and experience that would qualify candidate for the position.

Preferred

• Bachelors in science in Nursing (BSN).
• Experience with mental health/addiction disease services (strongly preferred).

Certificates, Licenses, and/or Registrations

• Valid, unrestricted Oregon RN license.

Physical Demands & Work Environment The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this position. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit, stand, walk, use hands and fingers, handle or feel, and reach with hands and arms. The employee is occasionally required to climb or balance, stoop, kneel, crouch or crawl. The employee may occasionally need to lift and/or move up to 25 pounds.

This position operates in a professional office environment and requires frequent use of standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Specific vision abilities required by this job include close vision, color vision, distance vision, depth perception, and ability to adjust focus. The noise level in the work environment is usually moderate. This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.