Care Manager - RN

Location: 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 - RN) performs outlined Care Management (CM) duties for priority population members, members with mental health and addictions issues, and chronically ill Medicaid members with diagnoses that include chronic kidney disease, diabetes, chronic obstructive pulmonary disease (COPD), and cardiovascular disease. The CM - RN 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

• Provides day-to-day CM and Care Coordination services for Yamhill Community Care (YCCO) members.

• Builds and maintains relationships with YCCO members, providers, and community partners to ensure care needs are identified and positive outcomes are met.

• Collaborates with staff, providers, and community partners to establish and make available resources and support that meets the needs of YCCO members.

Job Duties

• Reviews CM referrals received from members, providers, community partners, and the plan.

• Makes appropriate referrals both internally and externally to appropriate departments / resources.

• 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.

• Advocates for members and families where member concerns are heard, access to providers is facilitated, community resources are made available, and medications are managed.

• 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.

• 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.

• Utilizes nursing processes with a focus on best practice for interventions and outcomes with care plan routinely updated.

• Applies Population Health Management tools to maximize benefits of chronic disease management prevention and wellness campaigns.

• 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 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.

• 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 CM program.

• 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.

Essential Department & Organizational Functions

• Works to cultivate and develop inclusive and equitable services, and working relationships with diverse groups of employees, community partners, and community members.

• Participates in the preparation and submission of regulatory and contract required deliverables.

• Works closely with other YCCO departments, including Health Plan Operations and Compliance to assist with audits; including the External Quality Review (EQR), as needed.

• Proposes and implements process improvements.

• Meets deadlines for completion of assigned responsibilities and projects.

• Maintains agreed upon work schedule with punctual, regular, and predictable attendance.

• Demonstrates cooperation and teamwork using a professional and respectful demeanor.

• Provides cross-training on specific job responsibilities.

• Meets identified goals that contribute to departmental goals.

• Works collaboratively in a team and matrixed (cross-department) environment with a spirit of cooperation.

• Respectfully takes direction from Supervisor.

• Other duties as assigned.

Knowledge, Skills, & Abilities

• Bilingual Spanish / English strongly preferred.

• Strong working knowledge of chronic disease states and basic medical management of these states.

• 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.

• 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.

• 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.

• Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook.

• Ability to communicate both professionally and effectively in all forms of communication.

• Ability to work in an environment with diverse individuals and groups.

• Ability to remain flexible, positive, and adaptable.

• Ability to work across the YCCO region and to work remotely, as needed.

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.

Education & Experience

Required:

• Graduate from accredited school for social work, counseling, nursing, or related healthcare field.

• Minimum 1-3 years of work experience in community behavioral health setting including experience with CM, disease management, and/or quality improvement.

• Minimum 1-2 years of clinical experience in an area such as medical / surgical, skilled nursing, mental health or addictions medicine.

OR:

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

Preferred:

• Licensed Clinical Social Worker (LCSW), Licensed Master of Social Worker (LMSW), Licensed Professional Counselor (LPC), or equivalent license, preferred.

• Bachelors in science in Nursing (BSN).

• Experience with mental health / addiction disease services (strongly preferred).

Certificates, Licenses, and/or Registrations

• Valid, unrestricted Behavioral Health Clinical license in Oregon.

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.