OU Sooner Health Access Network

RN Care Manager Team Lead

Purpose of Job: The RN Care Manager Team Lead is responsible for providing assistance to management, including hiring and training, and keeping management updated on team and individual performance.

The RN Care Manager Team Lead is also responsible for all aspects of care for high risk members with chronic behavioral and/or health conditions, partnering with members and their caregivers, physicians and the health care team to provide timely access to ongoing and long term needed care, continuity of care across all settings, informed and shared decision making, and linkages to supportive services and community resources.  This also includes palliative care.

Hybrid Position – Combination home and office setting, in addition to noted home visits, and primary care and specialty visits, etc.

Major Responsibilities:

RN Team Lead

• Serve as a subject matter expert in care management processes and procedures.
• Model the culture and philosophy of the Department.
• Train and mentor care managers.
• Available for urgent staffing with care managers.
• Participate in the hiring process of new care managers, as requested.
• Participate in the development of processes and procedures, as requested.
• Participate in annual employment evaluations, as requested.
• Participate in closure review team, including completion of assigned closure reviews.
• Serve as an active member of the training team.

RN Care Manager

• Identify and document member’s goals.
• Assessment of member’s medical and behavioral health, and social determinants of health.
• Assess barriers to achieving goals including health status, functional abilities, behavioral health, social issues, environmental and safety concerns, caregiver stability, self-management skills, and life care planning.
• Assess member’s strengths and confidence in achieving goals.
• Monitor and evaluate plans including progress toward goals, health status, medication reconciliation and member experience.
• Review and interpret medical test results.
• Evaluate effectiveness of medical treatments.
• Recognize and communicate signs and symptoms of change in member’s health status
• Provide consultation to LCSW care managers concerning disease processes and medical management.

• Depending on the care management pathway followed, contact is provided daily to at least monthly to members:
  • home visits to evaluate home environments and family relationships, and to provide support and self-management coaching.
  • medical and psycho-social appointments to facilitate collaboration.
  • telephone calls.
  • hospital visits.
  • secure email.

• Crisis management.
• Link member and caregiver to supportive community services as needed and follow up to confirm contact.
• Facilitate access, communication and collaboration between member and all providers.
• Provide and coordinate transition services across all settings of care.
  • Communicate care plan to all providers in all settings of care (Emergency Department, hospital, rehabilitation facility, home care, nursing home and specialists).
  • Ensure member, caregivers and providers receive timely information for treatment decisions across all settings.
  • Coordinate/verify services, equipment and supplies are in place.
  • Reconcile medications at every contact.
• Regularly maintain records to document and monitor the care management activities in the management information system.
• Participate in regular interdisciplinary case staffing meetings and reviews.
• Communicate and collaborate with other providers (e.g., specialists, respiratory therapists, nutritionists, physical therapists, home health providers, care managers, social workers, etc.) by optimizing the office-based care team to send, receive, and triage information flows among the providers.
• Communicate with, educate and advise members and family, helping them to understand conditions and treatments.
• Participate in Quality Improvement activities.
• Monitor identified performance measures and deliverables and provide regular progress reports - Report submission will be determined as performance measures and deliverables are identified.
• Follow and practice defined evidence based protocols in all care management related activities and responsibilities.
• Other duties as assigned.

Values:

• Demonstrate and apply principles of person-centered, strength-based philosophy, motivational interviewing, shared decision making, coaching and adult learning.
• Demonstrate a sensitivity and responsiveness to a variety of cultural values and beliefs and social determinants of health.
• Practice trauma informed approach.

Community Representative:

Serve as an OU representative on community boards and task forces.