RN Care Manager

The RN Care Manager is responsible for providing comprehensive care coordination, health education, and population management services for patients enrolled in Managed Medicaid programs. This role supports high-risk and medically complex patients by conducting assessments, developing person-centered care plans, facilitating transitions of care, and addressing social drivers of health. The RN Care Manager collaborates closely with primary care providers, behavioral health teams, social workers, and external partners to ensure timely, integrated, and equitable care.

Key Responsibilities:

• Perform telephonic and in-person assessments to identify clinical, behavioral, and social needs.
• Develop individualized care plans and monitor progress toward goals.
• Coordinate care across primary care, specialty services, hospitals, and community resources.
• Support transitions of care, including hospitalization follow-ups and medication reconciliation.
• Provide patient education on chronic disease management, preventive care, and health system navigation.
• Track and document care coordination activities in the EHR to meet Managed Medicaid and quality program requirements.
• Participate in interdisciplinary team meetings to support comprehensive, patient-centered care.

Qualifications:

• Current RN license in applicable state.
• Experience in care management, community health, or Medicaid populations preferred.
• Strong communication, critical thinking, and problem-solving skills.
• Ability to work collaboratively in a multidisciplinary, fast-paced environment.

SUMMARY:

The RN Care Manager addresses the needs of the population served by assessing, planning, implementing, coordinating, monitoring, and evaluating the options and services required and using communication and available resources to promote quality, cost-effective health outcomes. Working within the RN scope of practice, and in concert with the Primary Care Provider, patient, caregivers, family members, other members of the Care Management Team and the community to coordinate a full continuum of health care services considering the holistic needs of the member, inclusive of unique social and cultural dynamics. In addition, this position will support MedNorth Health Center (MNHC) goals and objectives in meeting performance improvement targets for various initiatives; data analysis that supports care management, standardized plan of care expectations, and patient team development. Other duties may be assigned to support the development of the network.

This position works to achieve the goals and objectives within the scope of work of the current grant requirements for the Office of Rural Health – Community Health Grant for the duration of the grant life cycle.

PRIMARY DUTIES and RESPONSIBILITIES:

The Primary Duties and Responsibilities include the following: (other duties may be assigned):

• Provide effective Care Management services based on case management standards of practice to enrolled populations.
• Provide oversight for the incorporation of annual wellness visits, care gap closure and wellness visits for Medicare patients while working within the Aledade app.
• Complete comprehensive assessments considering the total individual, inclusive of medical, biopsychosocial, behavioral, spiritual, and cultural needs to enrolled population, throughout the continuum of care.
• Review, implement and evaluate the member care plan in partnership with the member, caregiver/family members, providers, and Care Management team members, as applicable.
• Work with patients to identify behavioral, social, cultural, and environmental strengths and challenges as it relates to his/her diagnosis, treatment, and access to care.
• Identify and address barriers that impede health outcomes and address with the help of the community health worker.
• Implement Care Management interventions per the patient’s care plan.
• Work in conjunction with patient to formulate, develop, and implement patient-centered plans using therapeutic skills and techniques such as trauma-informed care, motivational interviewing, strengths-based, and solution-focused modalities.
• Provide education to patient/family about clinical diagnosis, medications, available resources, prevention, and risk factors to achieve optimal self-management.
• Work in concert with the CHW to address Social Determinants of Health.
• Utilize therapeutic skills and techniques to help patients achieve healing, growth, health, and wellness.
• Monitor quality and effectiveness of interventions to the enrolled populations by setting patient-centered SMART goals in collaboration with the patients/families
• Processes referrals to members of the patient engagement team (social work, behavioral health, community resource coordinators) and/or clinical team (pharmacy, pharmacy technician, patient coordinator) appropriately, accurately, and timely according to established workflows
• Serve as a liaison among the patient/family, community services, primary providers, specialists, and other care team members to coordinate services without duplication.
• Work collaboratively with multi-disciplinary team members to facilitate achievement of desired treatment outcomes.
• Maintain appropriate member documentation in the Care Management documentation platform, in accordance with organizational policies and procedures.
• Engage and maintain collaborative relationships with community provider agencies that promote quality care and cost-effective health care utilization.
• Adhere to MNHC privacy and security policies to ensure that patient and network data are properly safeguarded.
• Abide by department guidelines, company policies, and HIPAA regulations.
• Attends departmental and corporate meetings, local and regional trainings, or other events as required.
• Willingly performs other duties as assigned.

Corporate Compliance: It is an essential job element that everyone be compliant with the full law and fully cooperate with the compliance program without fear of retaliations from the organization.

SUPERVISORY RESPONSIBILITIES: N/A

ADMINISTRATIVE RESPONSIBILITIES: N/A

WORK ENVIRONMENT: The work environment characteristics described herein are representative of those an employee encounters while performing the essential functions for this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

MedNorth Health Center provides comprehensive health care services, inside a multi-cultural medical/dental clinic, to all individuals; insured, uninsured, and underinsured. The building is heated in winter and air conditioned in the summer with noise levels of moderate to loud. We serve patients who speak multiple languages and who may need the assistance of an interpreter. In this position one may be subject to exposure to copier toner, correction fluid, bright fluorescent lighting, and continuous personal computer exposure.

This job is a Blood borne Pathogens risk category III position.

GENERAL EXPECTATIONS:

The employee is expected to attend work on a daily basis and to be at work on time.

The employee is expected to be a team player.

The employee is expected to report absences in accordance with personnel policies and procedures.

The employee's work is expected to be accurate, neat, and thorough, and completed on time.

The employee is expected to have a positive attitude, be cooperative, and considerate of others.

The employee is expected to be dependable and is expected to accept responsibility for assignments and duties given.

The employee is expected to dress and act in a professional manner and adhere to all safety standards.

The employee is expected to participate in staff meetings, be courteous and polite with patients and other staff.

The employee is expected to maintain confidentiality.

QUALIFICATION REQUIREMENTS: The requirements listed below are representative of the knowledge skills, and/or ability desired:

EDUCATION AND/OR EXPERIENCE:

RN: bachelor’s degree or better from an accredited School of Nursing with an unrestricted license to practice nursing in NC; Certified Case Manager (CCM) a plus. A Minimum of (5) five years of nursing experience in an ambulatory or acute care setting, home health, or public health.

ADDITIONAL SKILLS REQUIRED: Excellent verbal communication skills. Must be able to work with changing priorities. Requires excellent organizational, problem solving and critical thinking skills. Must be able to interact with individuals of all cultures and levels of authority. Requires the ability to maintain confidentiality. Must be able to function as part of a team. Experience with electronic documentation systems is preferred.

Knowledge, Skills and Abilities

• Excellent and effective written and oral communication skills.
• Proficiency in Microsoft Office Outlook, Word, Excel, PowerPoint use and e-mail communication.
• Ability to communicate clearly and succinctly.
• Dependable, manages time well; efficient and organized.
• Ability to produce accurate work; ability to perform multiple tasks in a proficient and timely manner.

LANGUAGE SKILLS: Ability to speak English fluently. The ability to speak other languages is a plus.

PHYSICAL DEMANDS: The physical demands described herein are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation will be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to stand, walk, talk, and hear, use hands and fingers, handle or feel. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee is frequently required to lift and/or move up to 20 pounds.

The special vision requirements for this job are close vision (clear vision at 20 inches or less), as well as distant vision and color vision (ability to identify and distinguish colors).

An individual in this position must have the ability to uphold the stress of traveling. This position could require up to 50% travel. Regular, predictable attendance is required.