RN/LCSW Care Manager Lead

SUMMARY

The RN or LCSW Lead Care Manager addresses the needs of the population served by assessing, planning, implementing, coordinating, monitoring, and evaluating the options and services required and using communication and available resources to promote quality, cost-effective health outcomes.  Working within the Registered Nurse or Licensed Clinical Social Worker scope of practice, and in concert with the Primary Care Provider, patient, caregivers, family members, other members of the Care Management Team and the community to coordinate a full continuum of health care services considering the holistic needs of the member, inclusive of unique social and cultural dynamics. This individual will supervise the care coordinators and community health workers assigned to the target population. In addition, this position will support MedNorth Health Center (MNHC) goals and objectives in meeting performance improvement targets for various initiatives; data analysis that supports care management, standardized plan of care expectations, and patient team development.  Other duties may be assigned to support the development of the network.

PRIMARY DUTIES and RESPONSIBILITIES:

The Primary Duties and Responsibilities include the following: (other duties may be assigned):

• Provide effective Care Management services based on case management standards of practice to enrolled populations.
• Complete comprehensive assessments considering the total individual, inclusive of medical, biopsychosocial, behavioral, spiritual, and cultural needs to enrolled population, throughout the continuum of care.
• Develop, review, and evaluate the member care plan in partnership with the member, caregiver/family members, providers, and Care Management team members, as applicable.
• Supervise the care program and employees within it to include care coordinators and community health workers.
• Work with patients to identify behavioral, social, cultural, and environmental strengths and challenges as it relates to his/her diagnosis, treatment, and access to care.
• Identify and address barriers that impede health outcomes.
• Implement Care Management interventions per the patient’s care plan.
• Work in conjunction with patient to formulate, develop, and implement patient-centered plans using therapeutic skills and techniques such as trauma-informed care, motivational interviewing, strengths-based, and solution-focused modalities.
• Provide education to patient/family about clinical diagnosis, medications, available resources, prevention, and risk factors to achieve optimal self-management.
• Utilize therapeutic skills and techniques to help patients achieve healing, growth, health, and wellness.
• Monitor quality and effectiveness of interventions to the enrolled populations by setting patient-centered SMART goals in collaboration with the patients/families.
• Processes referrals to members of the patient engagement team (social work, behavioral health, community resource coordinators) and/or clinical team (pharmacy, pharmacy technician, patient coordinator) appropriately, accurately, and timely according to established workflows
• Serve as a liaison between the patient/family, community services, primary providers, specialists, and other care team members to coordinate services without duplication.
• Work collaboratively with multi-disciplinary team members to facilitate achievement of desired treatment outcomes.
• Maintain appropriate member documentation in the Care Management documentation platform, in accordance with organizational policies and procedures.
• Engage and maintain collaborative relationships with community provider agencies that promote quality care and cost-effective health care utilization.
• Adhere to MNHC privacy and security policies to ensure that patient and network data are properly safeguarded.
• Abide by department guidelines, company policies, and HIPAA regulations.
• Attend departmental and corporate meetings, local and regional trainings, or other events as required.
• Willingly performs other duties as assigned.

Corporate Compliance: It is an essential job element that everyone be compliant with the full law and fully cooperate with the compliance program without fear of retaliations from the organization.           

SUPERVISORY RESPONSIBILITIES:  Care Coordinators and Community Health Worker

ADMINISTRATIVE RESPONSIBILITIES:  N/A

QUALIFICATION REQUIREMENTS: The requirements listed below are representative of the knowledge skills, and/or ability desired:

EDUCATION AND/OR EXPERIENCE:

RN: Bachelor’s Degree or better from an accredited School of Nursing with an unrestricted license to practice nursing in NC; Certified Case Manager (CCM) a plus.  A Minimum of (5) five years of nursing experience in an ambulatory or acute care setting, home health, or public health.  A minimum of at least two years of supervisory experience or comparable experience.  

LCSW: Licensed as a Social Worker to practice in the state of NC; Certified Case Manager (CCM) a plus; A minimum of (5) years of social work experience in an ambulatory or acute care setting, home health, public health, or mental health facility.

ADDITIONAL SKILLS REQUIRED:   Excellent verbal communication skills. Must be able to work with changing priorities.  Requires excellent organizational, problem solving and critical thinking skills. Must be able to interact with individuals of all cultures and levels of authority. Requires the ability to maintain confidentiality.  Must be able to function as part of a team.  Experience with electronic documentation systems is preferred.           

Knowledge, Skills and Abilities

• Excellent and effective written and oral communication skills.
• Proficiency in Microsoft Office Outlook, Word, Excel, PowerPoint use and e‐mail communication.
• Ability to communicate clearly and succinctly.
• Dependable, manages time well; efficient and organized. 
• Ability to produce accurate work; ability to perform multiple tasks in a proficient and timely manner.

LANGUAGE SKILLS:  Ability to speak English fluently.  The ability to speak other languages is a plus.

PHYSICAL DEMANDS:    The physical demands described herein are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to stand, walk, talk, and hear, use hands and fingers, handle or feel.  The employee is occasionally required to stoop, kneel, crouch or crawl.  The employee is frequently required to lift and/or move up to 20 pounds.

The special vision requirements for this job are close vision (clear vision at 20 inches or less), as well as distant vision and color vision (ability to identify and distinguish colors).

An individual in this position must have the ability to uphold the stress of traveling.  This position could require up to 50% travel.  Regular, predictable attendance is required.

WORK ENVIRONMENT: The work environment characteristics described herein are representative of those an employee encounters while performing the essential functions for this job.  Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The job will be performed inside a multi-cultural medical/dental clinic, which delivers comprehensive health care services to the disadvantaged and underserved.  The building is heated in the winter and air conditioned in the summer with noise levels of moderate to loud. Children crying and screaming. Loud talking patients.  Patients speaking multiple languages at the same time. Loudspeaker and/or paging.  One must have the ability to work in a confined area and sit at a computer terminal for an extended period or drive long distances.

This job is a Blood borne Pathogen’s risk category I position.

GENERAL EXPECTATIONS:

The employee is expected to attend work on a daily basis and to be at work on time.

The employee is expected to be a team player.

The employee is expected to report absences in accordance with personnel policies and procedures.

The employee's work is expected to be accurate, neat, and thorough, and completed on time.

The employee is expected to have a positive attitude, be cooperative, and considerate of others.

The employee is expected to be dependable and is expected to accept responsibility for assignments and duties given.

The employee is expected to dress and act in a professional manner and adhere to all safety standards.

The employee is expected to participate in staff meetings, be courteous and polite with patients and other staff.

            The employee is expected to maintain confidentiality.