RN - Care Manager - Population Health

Working in the OU Health Memory Care Clinic, the RN Care Manager will provide ongoing contact with patients and caregivers in order to maintain the person-centered care plan, identify unmet needs and coordinate clinical and community-based services and support, monitor medication adherence, and provide caregiver education.

The Population Health Nurse Care Manager works with the Primary Care Physician and care team to improve the health of patients. The RN Care Manager will incorporate both face-to-face and telephonic based services to work collaboratively with the patient, caregiver, provider, and care team. The Care Manager will ensure patients have the support, resources, education, follow-up appointments, and home care needed to improve outcomes and reduce the risk of re-hospitalization.

General Description: Responsible for the case management process including admission, assessment/reassessment, service planning, monitoring and discharge of consumers. Provides support to cope with chronic or acute illnesses or conditions.

Under general supervision, mentors new or lower level case managers, facilitating their growth and development in the role and ensuring their success in case management. Performs independently and requires a broad understanding of principles and practices. Performs additional clinical tasks and responsibilities that may be performed or undertaken by an RN including, but not limited to, responsibility for assessment of critical need or high risk patients to ensure that the appropriate level of care is prescribed and provided, and participation in case management programs that require clinical assessments.

Essential Responsibilities:

• Liaison. Advises care givers, provides patient education and counseling, and makes referrals for other services. May also provide care and case management or interventions designed to promote health, prevent disease, and address barriers to access to healthcare.
• Assessment. Collects in-depth information about a client's situation and functioning through client interview and other relevant sources to identify individual needs. Develops a comprehensive case management plan that will address identified needs. Monitors, and evaluates treatment plans and progress. Facilitates interdisciplinary approaches. Monitors staff performance.
• Planning and Implementation. Develops and implements action-oriented and time specific case management plans by determining and documenting specific objectives, goals, and actions designed to meet the client's health and human service needs identified through the assessment process.
• Coordination. Organizes, secures, integrates, modifies, and documents the resources necessary to accomplish the goals set forth in the case management plan.
• Monitoring and Evaluation. Gathers information and documentation from all relevant sources regarding the case management plan's activities and/or services to determine the plan's effectiveness in reaching desired outcomes and goals. Modifies or changes the case management plan, as needed.
• Outcomes. Measures and analyzes the interventions to determine the outcomes of case management involvement, e.g. clinical, financial, variance, quality/quality of life, client satisfaction.
• Orients and educates consumers, maintains records of service delivery, serves as liaison between the program and other agencies, conducting quality improvement audits, and report preparation.

General Responsibilities:

• Performs other duties as assigned.

Minimum Requirements:

Education:Bachelor's Degree in Nursing

Experience: 1 year of professional nursing experience.

Equivalent/ Substitution:Will accept an Associate's degree in Nursing and 2 years of professional nursing experience in lieu of the Bachelor's Degree for a total of 36 months professional nursing experience.

Licensure/Certifications/Registrations Required: State of Oklahoma Registered Nurse Certification.

Knowledge, Skills & Abilities:

• 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.