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RN Care Manager

4 months ago

Tulsa, United States University of Oklahoma Full time
Job Description

OU Sooner Health Access Network

Purpose of Job: The RN Care Manager is responsible for all aspects of care for complex high-risk members with chronic behavioral and/or health conditions, partnering with members and their caregivers, physicians and the health care team to provide timely access to ongoing and long term needed care, continuity of care across all settings, informed and shared decision making, and linkages to supportive services and community resources. This also includes palliative care.

NOTE: This position is a full-time remote position in Oklahoma City Area reporting to managers in Tulsa. The RN Care Manager will be provided with a laptop and monitors to be based from home in the OKC area. Travel is required to Tulsa occasionally for meetings. Care management is completed telephonically and in person with members during home visits, clinic, hospital and specialty visits, etc.

Major Responsibilities:
  • Collaborate with members to create a member's plan of care, including identifying goals, barriers and strengths.
  • Clinical assessment of member's medical and behavioral health, and social determinants of health.
  • Assess barriers to achieving goals including health status, functional abilities, behavioral health, social issues, environmental and safety concerns, caregiver stability, self-management skills, and life care planning.
  • A ssess member's strengths and confidence in achieving goals.
  • Conduct ongoing medication reconciliations including assessing for barriers.
  • Monitor and evaluate plans including progress toward goals, health status, medication reconciliation and member experience.
  • Review and interpret medical test results.
  • Evaluate effectiveness of medical treatments.
  • Recognize and communicate signs and symptoms of change in member's health status.
  • Depending on the care management pathway followed, contact is provided daily to at least monthly to members:
o home visits to evaluate home environments and family relationships, and to provide support and self-management coaching.

o medical and pycho-social appointments to facilitate collaboration

o telephone calls.

o hospital visits.

o secure email. Understands and is able to apply the concepts of disease management and risk management in service planning.
  • Utilize critical thinking to assess alternative approaches to problems and/or decisions.
  • Review and interpret therapist reports and psychiatry reports.
  • Recognize and communicate with team any signs and symptoms of changing mental health needs.
  • Crisis management.
  • Link member and caregiver to supportive community services as needed and follow up to confirm contact.
  • Facilitate access, communication and collaboration between member and all providers.
  • Provide and coordinate transition services across all settings of care.
    • Communicate care plan to all providers in all settings of care (Emergency Department, hospital, rehabilitation facility, home care, nursing home and specialists).
    • Ensure member, caregivers and providers receive timely information for treatment decisions across all settings.
    • Coordinate/verify services, equipment and supplies are in place.
    • Reconcile medications at every contact.
  • Regularly maintain records to document and monitor the care management activities in the management information system.
  • Participate in regular interdisciplinary case staffing meetings and reviews.
  • Communicate and collaborate with other providers (e.g., specialists, respiratory therapists, nutritionists, physical therapists, home health providers, care managers, social workers, etc.) by optimizing the office-based care team to send, receive, and triage information flows among the providers.
  • Communicate with, educate and advise members and family, helping them to understand conditions and treatments.
  • Participate in Quality Improvement activities.
  • Monitor identified performance measures and deliverables and provide regular progress reports - Report submission will be determined as performance measures and deliverables are identified.
  • Follow and practice defined evidence-based protocols in all care management related activities and responsibilities.
  • Conduct assessments and monitoring within prescribed timelines.
  • Other duties as assigned.
Values:
  • Demonstrate and apply principles of person-centered, strength-based philosophy, motivational interviewing, shared decision making, coaching and adult learning
  • Demonstrate a sensitivity and responsiveness to a variety of cultural values and beliefs and social determinants of health
  • Practice trauma informed approach
Community Representative:
  • Serve as an OU representative on community boards and task forces
Job Requirements

Required Education: Bachelor's Degree in Nursing AND:
  • 12 months of professional nursing experience.
Equivalent/Substitution: Will accept an Associate's degree in Nursing and 24 months of professional nursing experience in lieu of the Bachelor's Degree for a total of 36 months professional nursing experience.

Certifications: State of Oklahoma Registered Nurse Certification.

Skills:
  • Knowledge of federal and state laws particularly patient confidentiality.
  • Knowledge of case management fundamentals and the technical/procedural aspects of case management.
  • Knowledge of medical terminology
  • Ability to resolve moderate to complex issues applying judgment, critical thinking and problem solving skills to determine a proper course of action.
  • Must have a high level of organizational skills in order to prioritize, organize, and complete projects or documents in a timely manner.
  • Ability to keep accurate, detailed records.
  • Ability to handle stressful situations and different situations and circumstances.
  • Ability to set priorities and manage obstacles while maintaining focus on goals.
  • Ability to build and maintain professional relationships with clients, colleagues, and other agencies while following ethical standards of practice.
  • Must be self-motivated to achieve results, be flexible when changes are necessary, and respond to feedback in a positive manner.
  • Ability to analyze information and evaluate results to determine the proper course of action while following established standards.
  • Ability to develop and maintain cooperative working relationships.
Working Conditions:
  • Physical: Sitting for long periods of time. Speaking and listening.
  • Environmental: Office Environment.

Why You Belong at the University of Oklahoma: The University of Oklahoma fosters an inclusive culture of respect and civility, belonging, and access, which are essential to our collective pursuit of excellence and our determination to change lives. The unique talents, perspectives, and experiences of our community enrich the learning, and working environment at OU, inspiring us to harness our innovation, creativity, and collaboration for the advancement of people everywhere.

Equal Employment Opportunity Statement: The University of Oklahoma, in compliance with all applicable federal and state laws and regulations, does not discriminate based on race, color, national origin, sex, sexual orientation, genetic information, gender identity, gender expression, age, religion, disability, political beliefs, or status as a veteran in any of its policies, practices, or procedures. This includes, but is not limited to, admissions, employment, financial aid, housing, services in educational programs or activities, and health care services that the University operates or provides.