RN Care Manager

Job Description:

About the Role: 

The RNCM manages a panel of rising and high intensity members to support integrated chronic disease and behavioral health care for the members.  The RNCM collaborates with members to create a care plan and oversees progress to the plan, frequently reassessing needs, coordinating with providers and specialized resources, and partnering closely with the Community Health Partner to build trust and demonstrate advocacy.

Responsibilities:

Engagement

• Receives members from engagement and care team

• Describe program expectations (e.g., length) and goals to members

Assess/Intake

• Complete self-efficacy and relevant condition-specific screeners with members

  • Complete additional tools or screeners as needed, including relevant behavioral health screeners (e.g., PHQ9, GAD-7, AUDIT, DAST-10)

• Triage members with need for behavioral health programming

• Conduct an in-person clinical exam, if appropriate

• Collaborate with care team members to determine need for member placement in a different program (e.g., lower or higher intensity programs)

Case Review and Care Planning

• Prep and active participant in case conference, leading discussion as appropriate 

• Develop care plan with the member, collaborate with Community Health Partner on social needs as needed

Clinical Visits and Follow-Up

• Regular check-ins with member as guided by program

• Follow-up on routine therapeutic interventions by internal or external providers (in collaboration with care team)

• Address and responds to member needs and delegate tasks in timely fashion

• Collaborate on a panel of members assigned to your care team to provide clinical support, including health maintenance, chronic disease management and co-occurring psychiatric disorder support

  • Medication reconciliation, administration, compliance, education and home monitoring

• Address contracted and company prioritized quality gaps and ensure proper chart documentation and codes (ICD or CPT) are included in the encounter as supporting evidence of gap closure

• Support members in achieving their care plan goals

Operations

• Utilize our care facilitation, electronic health record and scheduling platforms as needed to collect data, document member interactions, organize information, track tasks, and communicate with your team, members, and community resources

Requirements for the Role: 

• Graduate of an accredited school of nursing (R.N.)

• 3+ Years of experience

• Basic Life Support (BLS) certification is a requirement

• Active RN License in the state(s) practicing

  Unrestricted Driver’s License

• Comfortable using technology to support members without in-person contact (telephone and text etiquette, virtual visit platforms, etc.)

• Understanding of how to use scheduling platforms to ensure accurate appointment scheduling and management

• Understanding of how to use electronic health record systems and/or care facilitation platforms to ensure accurate documentation

• Proficient in collecting member clinical and demographic data and documenting appropriately in a timely manner

• Strong problem solving skills - can make difficult decisions and knows when to collaborate with other team members

• Able to provide creative solutions to challenges within the healthcare system that are impeding optimization of members’ care and health

• Growth and learning mentality, ability to think outside the box, go outside the bounds of “traditional” responsibilities

• Adaptable to change and prepared for frequent, fast-paced changes and shifting priorities

• Versed in Motivational Interviewing and Trauma Informed Care principles

Cityblock values diversity as a core tenet of the work we do and the populations we serve. We are an equal opportunity employer, indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.