RN Care Manager, Population Health

Unclassified - Chapel Hill, NC

Full-time - Mid Level

Hybrid - Chapel Hill, NC

About the position

The RN Care Manager plays a crucial role within the Population Health Administration, working collaboratively as an integral member of an interprofessional primary care team. This position is dedicated to providing comprehensive, person-centered care management services to patients. The RN Care Manager's responsibilities encompass a wide range of activities, including patient education, medication management, adherence support, risk stratification, population management, and coordination of care transitions. The role also involves care navigation and referrals, ensuring that patients receive the necessary support and resources throughout their healthcare journey. In this position, the RN Care Manager will engage in outreach efforts, scheduled care management, and triage responses as needed. A key aspect of the role is the systematic and continuous collection and assessment of data related to patient health status, which is essential for developing, executing, and evaluating individualized care plans. The RN Care Manager will also be responsible for care coordination, health promotion, family support, and making referrals to necessary resources and supports. These functions may be performed in various settings, including community-based locations, during home visits, at MAHEC clinics, and remotely. Collaboration is a cornerstone of this role, as the RN Care Manager will work closely with Tailored Care Managers, Extenders (such as Peer Support Specialists and Community Health Workers), Care Navigators, MAHEC clinical teams, community partners, and other regional and state stakeholders. This collaborative approach ensures that patients receive seamless and integrated care that addresses their unique needs and circumstances.

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.
• Build and maintain a full patient panel by actively identifying patients who qualify for program benefits and initiates outreach.
• Develop outreach and engagement strategies to engage qualified patients.
• Complete referrals for unmet social determinant of health needs.
• Educate 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.
• Ensure required care management data and metrics are documented, tracked, and reported successfully to meet quality standards and guarantee closure of care gaps.
• Collaborate with MAHEC's clinical departments (Family Medicine, Internal Medicine, Pharmacy, OBGYN, and Psychiatry) and community resource organizations to ensure seamless care coordination/management for the population being served.
• Coordinate and may facilitate integrated Care Team meetings where patient Care Plan is discussed.
• Create a Care Management Crisis Plan and coordinate diversion efforts for patients at risk of admission to an institutional setting.
• Identify system barriers and collaborate to resolve issues with MAHEC departments and with community stakeholders.
• Collaborate with MAHEC's QI, central billing office (CBO) and audit team to perform regular claim review and education.

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).
• Valid driver's license.
• Current North Carolina nursing license or Board eligibility required.
• Current CPR certification required.

Nice-to-haves

• Fluency in Spanish preferred.