RN, Care Manager

Variety Care; Oklahoma City (OK); On-site; USD 55,000 - 75,000; Full time

Job summary

Variety Care is seeking an RN Care Manager in Oklahoma City to support high-risk patients within the Population Health program. You will organize, coordinate, and deliver care management services for patients at risk of deterioration and avoidable ER visits.

Responsibilities include comprehensive assessments, care planning, medication reconciliation, and collaboration with a multidisciplinary office team to optimize patient outcomes and self-management.

Qualifications

• Active RN license in good standing in Oklahoma.
• Two years of care management experience in a community setting preferred.
• BSN degree preferred; bilingual in English/Spanish is a plus.

Responsibilities

• Manage Variety Care’s high-risk patient population and coordinate care.
• Conduct comprehensive assessments of physical, mental, and psychosocial needs.
• Develop care plans to prevent disease progression and reduce ER utilization.
• Collaborate with care team and community partners to support transitions of care.
• Document progress and risk status in the electronic health record.

Skills

Oral and written communication

Bilingual English/Spanish

Education

RN license in Oklahoma

BSN degree preferred

Job description

Department: Population HealthPosition: RN Care ManagerEmployee Category: Non-ExemptReporting Relationship: Population Health ManagerCharacter Qualities:Alertness— Being aware of what is taking place around me so I can have the right responses.Dependability— Fulfilling what I consented to do, even if it means unexpected sacrifice.Flexibility—Willingness to change plans or ideas without getting upset.Sensitivity—Using my senses to perceive the true attitudes and emotions of others.Summary of Duties and Responsibilities:The RN Care Manager - Registered Nurse who directly supports Variety Care’s highest risk patients, with primary focus on at risk populations. In collaboration with other members of the healthcare team, the RN Care Manager is responsible for organizing, coordinating, and providing care management services, within the practice, who are at risk for health deterioration, poor health outcomes, and/or avoidable utilization of emergency care services.Primary Duties and Responsibilities:Manage Variety Care’s high-risk patient population.Conduct comprehensive assessment of patients’ physical, mental, and psychosocial needs.Develop care plans to prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, and minimize hospital and ER utilization.Reconcile patient’s medication list accurately and routinely.Communicate with providers (e.g.; specialists, respiratory therapist, nutritionist, physical therapist, home health providers, care managers, and social workers) by optimizing the office-based care team to send, receive, and triage information flows among providers.Utilize behavioral strategies including, but not limited to, Bridges out of Poverty, Crucial Conversations and Teach-Back techniques. Promote self-management goals that help patients adopt healthy behaviors and improves self-care.Optimize the utilization of services available at Variety Care, including Behavioral Health, Social Services, Community Health Worker, Enrollment Services, Nutrition, Pharmacy, Optical and Dental.Acts as a lead, for the care management team, of a subset of patients designated by the Population Health Manager, in coordination with the Director of Clinical Services. Assist the team (consisting of Social Services staff and Community Health Worker(s)) to prioritize and intervene effectively to keep patients medically stable and improve their quality of life as well as health outcomes.Coordinates/verifies that services, equipment and necessary supplies are in place.Participates in regular case staffing meetings and reviews.Follow-up with patients within 24 hours of inpatient discharge and within 48 hours of emergency department visit notification.Partner with external case management programs to coordinate care.Provide on-going evaluation and documentation of patient progress and risk status.Communicate and collaborate with internal care teams.Accurately documents and monitor care coordination activities in the electronic health record.Proactively support Variety Care’s initiatives related to care coordinationServe as a proactive member of care teams and team-based care initiatives.Partner with Variety Care staff to develop integrated care management programs.Serve as a professional role model for all staff.Adheres to all Variety Care policies and procedures.Supports Variety Care’s accreditation as a Patient Centered Medical Home and our commitment to provide care to all patients that is Safe, Effective, Patient Centered, Timely, Efficient, and Equitable. Provides leadership and works with staff to achieve the goals of the “Triple Aim” of healthcare reform – to improve the experience of care, improve health outcomes, and decrease healthcare costs.Serves as a Variety Care representative on community boards and task forces.Embodies the strength of personal character. Places value on being an open and honest communicator who displays high moral and ethical conduct, integrity, adaptability, and sound judgment. Must be a leader in the department and community. Result-oriented problem solver who is responsible and accountable.Performs other duties as assigned.Requirements, Special Skills or Knowledge:Active RN License in good standing in the state of Oklahoma.Excellent oral and written communication skills.Preferred requirements, Special Skills or Knowledge:Two years of experience in care management in a community-based setting.Bachelor of Science Degree in Nursing is preferred.Bilingual (English/Spanish).Essential Functions:Must be able to lift 25 pounds.