Community RN Care Manager

The Community RN Care Manager manages high-risk, chronic illness members to promote effective education, self-management support, and timely healthcare delivery to achieve optimal quality and financial outcomes. The Community RN Care Manager will formulate and implement a care management plan that addresses the member's identified needs by assessing issues, resources, and care goals. The Community RN Care Manager will advocate for the member and support the member in navigating the health care system.

Additionally, the Community RN Care Manager will collaborate with the interdisciplinary team and members PCP / Health Care Team to identify and support achieving the member's short-term and long-term health goals. HTA’s Care Management model is to provide longitudinal care management for identified members. A vital goal of the Community RN Care Manager within the longitudinal care management framework is to manage the post-acute care of identified members to avoid and limit poor health outcomes, frequent emergency room visits, and hospital readmissions.

Based on the RN’s work experience in nursing and knowledge of the health care system, the aims are to provide members with education and resources to reduce preventable emergency room visits, hospitalizations, and readmissions.

• Collaborates with providers and practice staff in identifying appropriate members for care management, utilizing established Care Management criteria.
  
  Performs initial and periodic holistic assessments for identified care-managed populations. This includes physical and psychosocial concerns for members as appropriate. The assessment consists of a systematic and pertinent data collection about the member's health status. Prioritizes members according to intensity, need, and required follow-up.
• Perform in-person visits with identified high-risk, high utilizer members in the home or facility settings to assess SDOH and transitional care needs.
• Formulate and implement a care management plan that addresses the member’s identified needs by assessing the member/family needs, issues, resources, and care goals; determining the choices available to individual members; and educating the patient/family on the choices available to meet their goals.
• Implements a care management plan mutually agreed upon by the health care team and the member/representative. Plans specific mutual self-management goals, objectives, and action-oriented interventions with the members.
• Evaluate the effectiveness of the care plan in meeting established care goals; revise the plan as needed to reflect changing needs, issues, and goals. Monitor and evaluate the member's progress at prescribed minimal intervals.
• Collaborates with the healthcare team to revise the care management plan when changes occur. Initiates/participates in care conferences to discuss multidisciplinary team responsibilities, member progress, new problems, etc.
• Identifies and effectively utilizes community resources to meet the SDOH needs of members/families. Facilitates member access to community resources as appropriate in collaboration with Social Work.
• Promotes member self-management and empowers members/families to achieve maximum wellness and independence. Interacts professionally with members/families and involves them in the formation of a plan of care.
• Performs transitional follow-up calls for members recently discharged from acute hospitalizations, with particular emphasis on those members who are at high risk for readmission. Performs in-person transitional care visits as directed for SDOH and needs assessment.
• Collaborates with providers and other healthcare team members, including inpatient facilities, outpatient providers, and the Utilization Management department, to initiate transitions of care and facilitate care across the healthcare continuum, and optimize clinical and financial outcomes.
• Determines and completes appropriate referrals to internal and external associates. Serves as a liaison to providers, members, and families to coordinate services.
• Participate in weekend rotation for member transitional care…