Job Purpose: Care Coordination Nurse
The Care Coordination program is a collaborative, comprehensive, integrated and interdisciplinary-focused Coordinated Care Organization (CCO) program staffed with team members focused on the addressing interrelated medical, social, cultural, developmental, behavioral, educational, spiritual and financial needs in order to achieve optimal health and wellness outcomes for each member in need.
This position is responsible for providing member focused assessment, care planning and service coordination for members with complex medical needs, including members with mental health, substance misuse, and/or social needs, and/or receiving facility based, in-home or community-based services. The Nurse Care Coordinator utilizes clinical expertise and assessment in medical, mental health, substance misuse, and/or social conditions, in coordinating services for the purpose of improving member self-management and overall health outcomes. This position is also responsible for assisting in auditing, reporting and oversight of external care coordination teams and provides network support.
Qualifications, Education, & Experience
- Current, unrestricted Oregon RN license; may consider experienced nurse with current, unrestricted Oregon LPN
- Certified Case Manager preferred, or willing to obtain
- Motivational interviewing and teaching experience a plus
- Associate’s Degree in Nursing from an accredited nursing program required, Bachelor’s preferred
- Three years’ experience in case management/care coordination
- Psychiatric care experience preferred
Essential Responsibilities: Clinical Assessment & Care Coordination - Assess for and identify care coordination needs in order to implement care coordination program to members
- Identify risk factors and service needs that may impact member outcomes and address per guidelines
- Utilize a trauma-informed approach to provide member-focused care and support
- Assist in helping members move through the continuum of care based on clinical/medical need
- Utilize assessment information to develop individualized care plans for assigned members
- Coordinate with providers to ensure consideration is given to unique needs in integrated planning and that care plans are timely and effective
- Identify suspected abuse and neglect issues and appropriately report to mandated authorities
- Implement care coordination plan in collaboration with member, providers, case workers and other relevant parties
- Work closely and collaborate with behavioral health treatment providers, crisis services, Developmental Disability, APD, DHS, etc.
- Provide face to face, telephonic, videoconference and community-based care coordination to eligible members and families
- Assist members and families access the care and services they need without barriers
- Provide support and coordination for members receiving treatment in the higher levels of behavioral health care such as psychiatric residential treatment, intensive community based or psychiatric day treatment
- Ensure treatment recommendations are understood by the member and provider, and assist members through transitions to the next level of care or treatment provider
- Facilitate communication between members, their support systems other community-based partners and clinical care providers and ensure care plans are shared, as appropriate
- Accept assignment of and maintain a caseload of members
- Participate in an interdisciplinary team for integrated care plan support of complex members
- Collaborate with community providers, state and county case workers, community partners, vendors, agencies, provider network, wraparound teams, and other relevant parties
- Provide direction as appropriate to non-clinical Care Coordination staff involved with the member
- Assist in transition/discharge planning for members discharging from acute care settings or those who are transitioning from long term care, the Oregon State Hospital, or other residential facilities to ensure a smooth transition back to community-based supports
- Ensure discharge/transition plans are evaluated holistically from physical and behavioral health perspectives; may participate in monthly discharge planning meetings
- Coordinate care for members residing outside of service area as required in contract
- Forward relevant information of members requiring special consideration of benefits to Medical Management Review RNs or to affiliated Advanced Health programs
- Serve as a resource to the organization on mental health and alcohol and other drug topics and issues
- May provide coaching and training on specific job responsibilities to new employees, QMHP and/or Traditional Healthcare Workers (THW) in ICC team
- Participate in quality and organizational process improvement activities and teams when requested
- Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
- Handle confidential information and materials appropriately and maintain a secure work area
- Other duties as assigned
Essential Responsibilities: ORGANIZATIONAL TEAM MEMBER - Participate in quality and organizational process improvement activities when requested
- Support and contribute to effective safety, quality, and risk management efforts by adhering to established policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities
- Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner
- Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization
- Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer’s expectations
- Recognize new developments and remain current in care management and coordination best practice standards and anticipate organizational modifications
- Advance personal knowledge base by pursuing continuing education to enhance professional competence
- Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
- Represent organization at meetings and conferences as applicable
Knowledge, Skills, & Abilities: - Knowledge of Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for mental health and substance dependence/abuse diagnoses, ASAM (American Society of Addiction Medicine) criteria for alcohol and/or drug dependence treatment and Mental health
- Knowledge of best practices and treatment modalities
- Knowledge of co-morbidities that indicate potential for psychiatric de-compensation and/or relapse
- Knowledge of the Oregon Health Plan benefit package, eligibility categories, and Oregon Medical Assistance Program (MAP) rules and regulations
- Knowledge of Medicare parts A and B benefit packages and the Centers for Medicare and Medicaid Services (CMS) rules and regulations and community resources
- Maintain working knowledge of OHP benefits, including Addictions and Mental health benefits
- Understanding of principles of health care of populations
- Understanding of basic concepts of managed care
- Critical attention to detail for accuracy and timeliness
- High degree of initiative, judgment, discretion, and decision-making
- Ability to exercise sound clinical judgment, independent analysis, critical thinking skills, and knowledge of health conditions to determine best outcomes for members
- Ability to report to work as scheduled, and willingness to work a flexible schedule when needed
- Proficient in Microsoft Office Suite and Windows Operating System (OS)
- Training in or awareness of Health Literacy, Poverty Informed, Systemic Oppression, language access and the use of healthcare interpreters, uses of data to drive health equity, Cultural Awareness, Trauma-Informed Care, Adverse Childhood Experiences (ACEs), Culturally and Linguistically Appropriate Service (CLAS) Standards, and universal access
- Knowledge and understanding of how the positions’ responsibilities contribute to the department and company goals and mission
- Knowledge of federal and state laws including OSHA, HIPAA, Waste Fraud and Abuse
- Awareness and understanding of equity, diversity, inclusion, and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social, political, and environmental contexts of policies, programs, and practices
- Excellent people skills and friendly demeanor
- Critical thinking skills of using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems
- Attention to detail and organization skills
- Ability to handle stress and sensitive situations effectively while projecting a professional attitude
- Ability to communicate professionally, both conversing and written
- Ability to work with diverse populations and interact with people of differing personalities and backgrounds
- Sensitive to economic considerations, human needs and aware of how one’s actions may affect others
- Ability to organize and work in a sensitive manner with people from other cultures
- Poised; maintains composure and sense of purpose
Working Conditions:
This position must have the ability to remain in a stationary position, occasionally move about inside the office to access office machinery, printer, etc., frequently communicate and exchange accurate information.
Work Condition: Hybrid - Employee generally works within the interior of an office or remote work from home environment.
- Employee may travel locally and be responsible for own transportation. Out of area travel may be required on occasion.
- Hours of operations and specific staff scheduling may vary based on operational need.
- The office environment is clean with a comfortable temperature and moderate noise level.
Exposed to: - Onsite: Cold/heat controls, close contact with employees and the public in office environment. Remote: Employee is responsible for maintaining a safe work environment that is conducive to successful productivity and work output.
- Machines, equipment, tools, and supplies used: Constantly operates a computer or other office productivity machinery, such as postage machine, fax, copier, calculator, multi-line telephone system, scanner.
- May answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain or record information.
- Multiple Duties: Must be able to work under conditions of frequent interruption and be able to stay on task.
Other Information:
This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of Advanced Health employees. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.
Pay Range: $34.23 - $55.61 per hour
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