RN Care Manager, Population Health Specialist

2 weeks ago


Asheville, North Carolina, United States MAHEC, Mountain Area Health Education Center Full time
Job Summary

The RN Care Manager works collaboratively as an active member of the Population Health Administration as part of an interprofessional primary care team to provide comprehensive, person-centered care management services for patients. This includes patient education, medication management and adherence support, risk stratification, population management, coordination of care transitions, care navigation and referrals, and outreach, scheduled care management, and triage response as needed.

Key Responsibilities
  • Conduct intake assessments, screenings, and obtain necessary consents.
  • Develop person-centered care plans with Primary Care Providers and with guidance from supervisor and other clinical experts as needed.
  • Provide self-management education and bridge resources/services that are supportive of social and medical needs.
  • Support transition planning when patients are admitted/discharged from hospitals or other institutional settings.
  • Provide patient consultation in adapting treatment goals, identifying strengths, creating action items, and addressing barriers to goals.
  • Builds and maintains a full patient panel by actively identifying patients who qualify for program benefits and initiates outreach.
  • Develops outreach and engagement strategies to engage qualified patients.
  • Complete referrals for unmet social determinant of health needs.
  • Educates providers and clinical staff on program services, identifying qualified patients, and patient engagement tactics.
  • Work with MAHEC's Quality Improvement team to improve care management delivery and patient outcomes.
Requirements
  • Bachelor's degree in nursing.
  • A licensed registered nurse.
  • Two (2) years experience providing care management, case management, or care coordination to the population being served (Behavioral Health and/or I/DD).
Preferred Qualifications
  • Fluency in Spanish.
Work Environment

This position is hybrid with some travel and routinely scheduled attendance on-site. Typical business hours are Monday - Friday, 8:00 am to 5:00 pm (or flexed to best meet the needs of the clients and/or the Division); 40 hours per workweek; weekend, holiday, or evening coverage is occasionally required.



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