RN,Care Manager Job Levittown Pennsylvania USA,Healthcare

Department Overview

The Integrated Community Care Manager-RN provides one-site (face-to-face) and telephonic outreach, behavioral health, disease and/or care management, care coordination, care integration, care transition, education, support and navigation to OHSU Health Services Members with the goal of supporting healthy life choices and to reduce long term effects of chronic illness and decreasing ED and In Patient stays. The Integrated Community Care Manager-RN performs other clinically based activities to assist in the coordination and integration of care between the Member, his/her provider(s), health care facilities, health and behavioral clinics, and community-based healthcare organizations and agencies.

The Integrated Community Care Manager-RN enhances the quality of Member management by promoting continuity of care and cost effectiveness through whole person care management, care integration, and care coordination across the continuum of health care services.

* This is a remote position, however the person must live in the tri-county (Multnomah, Washington or Clackamas) area as there is a requirement to attend clinic visits and do home visits for patients/members. Function/Duties of Position

OHSU Health Services is committed tothe ongoing journey ofbeing an anti-racist organization that acknowledges the enduring impacts of historical injustices on health; addresses clinical,social, and structural systems and conditions that undermine health and wellness; strives to become a culturally-proficient workplace that reflects the communities served; and fosters an environment of belonging,respect, and inclusion where everyone feels empowered and safeto bring their full, authentic selves to the work.

Change requires individuals at all levels of the organization to be proactive in redistributing resources and power equitably by restructuring policies, clinical and financial strategies, culturally sensitive data analysis and the way data is used. OHSU Health unequivocally expects its staff and leadership to fully support this mission in these efforts.

Facilitate Health System Integration through cross-site communication and care coordination across the Integrated Delivery System and within the OHSU Health Service Area. Serve as a point of contract across transitions working closely with providers, facility and clinic care managers, and agency case workers to assist Members to navigate a complex healthcare system, as the Member moves across settings and systems. Foster a positive and professional relationship and act as a liaison with internal and external customers to ensure effective working relationships.

Coordinate care through assessing Members referred for care management services for clinical and psychosocial needs, and develop and implement patient-centered care plans that provide interventions including but not limited to disease management, medication management, and Member education and behavior modification within his/her scope of practice. Perform initial Assessments and initiate Care Plans as required by policy and for IDS Members as required by the contract held between OHSU Health Services and Health Share of Oregon and within the timelines established.

Reassessment of Member status and adjustment of care plans completed to meet Member on-going needs and goals of care. Monitor and evaluate services and community-based resources necessary to respond to the Member’s individual healthcare needs.

Provide Member care coordination and self-management through face-to-face and telephonic outreach, which may include home visits, attending clinic office visits, and interaction with patients being seen in the ED or who are in the hospital. These interventions are intended to allow the opportunity to assess the Member’s ongoing needs and to identify resources that will help ensure the Member is meeting his/her health care goals.

Collaborate with OHSU Health Services Member’s medical and healthcare community-based providers (that may include the primary care provider (PCP), specialist providers, behavioral specialists, dental providers, or others that may be indicated) regarding the Member’s…


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RN, Care Manager