RN Tailored Care Manager

JOB SUMMARY:

The RN Tailored Care Manager provides comprehensive, person-centered services to patients with complex behavioral/ mental health conditions, substance use disorders, and/or intellectual and developmental disabilities (I/DD). Required care management activities include care coordination, health promotion, transitional care planning and follow-up, family support, and referrals to necessary resources and supports. These functions may be preformed throughout WNC in community-based settings. The Tailored Care Manager will collaborate with care manager extenders (Peer Support Specialists, Community Health Workers), MAHEC clinical teams, community partners, and other regional and state stakeholders. They will report to an assigned Tailored Care Manager Supervisor.

SPECIFIC RESPONSIBILITIES:

• Conduct intake assessments and screenings and obtain necessary consents according to NCDHHS standards.
• Develop person-centered care plans, seeking guidance from supervisor and other clinical experts as needed.
• Provide self-management education as well as linkages to resources/ services supporting 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.
• 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. Ensure care management is successfully closing care gaps and meeting quality standards.
• 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.
• Provide 24:7 crisis response in rotation with other team members, which includes arrangement of services, consultation, or referral followed by coordination of care to an appropriate setting when necessary.
• 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.

This role description is a general description of the essential job functions.  It is not intended to describe all the duties the Tailored Care Manager may perform.

KEY COMPETENCIES:

• Communication Skills

Effectively and respectably communicate with other individuals, whether it be a colleague, patient, or patient’s family member and appropriately enumerate information in a manner easily understood by all parties. We do this to foster a culture of understanding between all parties, especially in complex and difficult situations, to ultimately provide the best care possible to our patients and their families.

• Decision Making

Ability to make the most appropriate decision in a given situation and then taking the next steps to ensure appropriate and timely completion. This requires conflict resolution skills, critical thinking skills, confidence in your ability to make the right decision in most situations. This also includes ability to prioritize your workday appropriately to ensure the most important tasks are completed on time.

• HealthCare Knowledge

Having the drive to keep yourself abreast and up to date on the new breakthroughs in your area of expertise and communicating them to the rest of the team, as appropriate.  This also includes keeping up with your licensure and yearly training requirements within your area expertise along with MAHEC’s organizational training. Finally, the ability to apply the depth of knowledge maintained and gained through this process in real life scenarios as appropriate.

• Interpersonal Skills

Showing the ability to meet difficult situations with grace, professionalism, and understanding. Within your area of expertise, showing respect and showing empathy where appropriate with your colleagues, patients, and their family at all times, even when its most difficult to do so. This is done, in part, by effective listening, being your authentic self, showing responsibility and dependa