Care Management RN - Lead

Who We Are:

Neighborhood Health Center is a non-profit organization local to Portland, OR serving underserved patients in the areas of primary care, internal medicine, dental services and more. Our patient-centered approach to care honors the unique needs and circumstances of each individual patient. NHC sees people, not problems, and recognizes that the time spent as a patient in a doctors office is only one factor in a persons overall health. Our leading edge, integrated clinical teams work in partnership with patients, their families, and the communities we serve to provide whole-person care, prevention, and ongoing support.

NHC is an Equal Opportunity Employer. We celebrate differences in the workplace and do not discriminate in employment opportunities or practices on the basis of race, color, religion, gender (sex), national origin, age, veteran status, sexual orientation, gender identity, disability, genetic information or any other characteristic protected by law.

Why work with us?

• We are a non-profit organization, passionate about providing the underserved population with medical and dental services across the greater Portland area, committed to making a difference daily.
• We offer our employees a competitive compensation and benefits package which includes 20 days of PTO (based on full time employment), 9 paid holidays, health/dental/vision insurance, quarterly wellness reimbursements, generous 401k retirement plan with employer match, employer paid disability insurance, EAP and life insurance.
• Our employees voted NHC a Top Workplace in 2020, 2021, 2022, and 2023!

Job Title: Lead Registered Nurse Care Manager
Department: Medical
Reports To: Director of Nursing and Clinical Services
Work Type: Hybrid
Schedule: Monday through Friday, 8am - 5pm
Location: Telecommuting / Tigard Admin Office / NHC Clinical Sites
Classification: Full-Time, Non-Exempt
Language Differential: Eligible

SUMMARY

The Lead Registered Nurse Care Manager provides effective transitional and chronic care management for an assigned panel of high-risk patients with chronic conditions, as well as those with complex psychosocial needs. This role is responsible for the active management, including transition management, of patients as the liaison between members of the patients care team, including specialty offices. The Lead Registered Nurse Care Manager works to improve patient health, wellness and autonomy through advocacy, communication, education, identification of service resources, and service facilitation. This role requires the ability to apply the nursing process (assessment, diagnosis, planning, implementation, and evaluation) to all care provided.

The Lead Registered Nurse Care Manager will deliver nursing care services to Neighborhood Health Center (NHC) patients both in person at a Primary Care Clinic setting or via the telephone from either the administrative office or from home.

The Lead Registered Nurse Care Manager is expected to understand and follow the Oregon Nurse Practice Act as administered by the Oregon State Board of Nursing and practice according to their scope of practice.

Essential Job Duties

• Actively participates in the development of care management standards and care delivery models within clinics and across NHC primary care.
• Able to define and implement Care Management and Care Coordination services at NHC .
• Utilizes evidenced-based models, such as Coleman’s “Four Pillars of Care Transition” or other identified model.
• Develops knowledge of CMS Chronic Care and Transitional Care Management Services.
• Oversight of RN Care Management Program, including development, implementation, and auditing of key workflows.
• Supports colleagues with resources, guidance, and hands-on collaboration as necessary.
• Monitors and reports on Care Management Key Performance Indicators to Nursing Manager, Director of Nursing and Clinical Services, and Clinic Manager.
• Attends organizational meetings as delegated by the Nursing Manager.
• Utilizes the nursing process to initiate, complete, update, and monitor the progress of comprehensive, culturally competent, person-centered, goal-oriented electronic care plans.
• Facilitates routine Care Management team huddles in partnership with medical providers.
• Daily work includes compiling recent patient hospital admissions and discharged census in preparation for weekly team huddle.
• Assists and promotes the identification of the targeted patient population who will benefit from care management.
• Performs hospital and emergency department follow up to ensure safe transitions of care for patients.
• Reviews medications and any potential interactions while assessing and supporting treatment adherence, including medication management, while performing transitions of care work.
• Offers and educates patients about timely recommended preventive services.
• Engages with patients who have chronic/complex, rising risk, and transitional care needs.
• Provides patient-centered strategies that help them succeed in self-care, self-advocacy, and achieving both healthcare and life goals.
• Educates, counsels, supports, and provides appropriate anticipatory guidance to the patient, family, guardian, or caregiver to support self-management, independent living, and activities of daily living for navigating complex medical decisions.
• May participate in provider visits for assigned patient panel.
• Facilitates patient care conferences as appropriate.
• Triages minor to emergent situations in person or telephonically to identify the nature and urgency of the patient's health care needs and then determines appropriate disposition, including scheduling of appointments in electronic medical record. NHC uses electronic triage protocols as a tool to assist in triage.
• Completes all in person and telephonic interactions in a timely, professional manner with courtesy and respect.
• Accepts responsibility for the interactive process that occurs in person and over the telephone with the patient.
• Manage an EPIC in-basket of patient calls, MyChart messages, and other messages that directly impact patient care plans.
• Provides care for patients using NHC approved clinical protocols.
• Accurately, concisely, and succinctly documents all patient contacts in the electronic medical record.
• Implements required nursing procedures consistent with NHC procedures/protocol.
• Participates in process and quality improvement workflows.
• Assists in new employee orientation, onboarding, training, as needed.
• Participates in the nursing team huddles at the start of the workday.
• Performs other duties as assigned.

QUALIFICATIONS

Education and/or Experience

• This position requires an Associate Degree in Nursing with at least 2 years of nursing experience; a Bachelor of Science in Nursing degree is preferred.
• This position requires completion from an accredited school of nursing.
• 2 years of previous Nurse Case Management experience is required.
• 1-3 years related experience and/or training in the FQHC, or primary care field, is preferred.
• Ability to fluently speak, read, and write in Spanish is highly preferred.
• Previous EPIC or EHR experience is preferred.
• Certificate in community and/or hospital case management, such as Certified in Care Coordination and Transition Management (CCCTM), Certification in Managed Care Nursing (CMCN) or Nursing Case Management Certification (CMGT-BC), is preferred.

License and/or Certification Requirements

• This position requires a current, unrestricted Oregon RN license.
• Active BLS certification is required.
• National Provider Identifier (NPI) is required.

Knowledge, Skills, Abilities & Behaviors

• Ability to work independently to the full ability of RN licensure.
• Knowledge of the principles, practices and procedures of community health nursing, managed care, and consultation, including socioeconomic and cultural factors, methods and techniques of crisis intervention.
• Ability to communicate professionally and effectively both orally and in writing with a service-oriented approach, sometimes in stressful circumstances, with patients, coworkers, and the public.
• Remains calm and effective in high pressure and emergency situations.
• Must demonstrate complex problem-solving skills.
• Able to complete work efficiently under set timelines.
• Must be able to display sensitivity to the population and patients served.
• Ability to use good judgement in difficult situations.
• Ability to proficiently use EPIC Electronic Health Record.
• Ability to comply with all HIPAA, OSHA, and Neighborhood Health Center policies and procedures.
• Working knowledge and proficiency of MS Office Suite (Outlook, Word, Excel) and desktop publishing software.
• Ability to learn and adapt to changing information and/or policies and procedures.
• Ability to enter data accurately with attention to detail.
• Knowledge of customer service principles and practices.
• Ability to work in a fast-paced environment.
• Ability to answer and utilize multiple line telephone.
• Must be able to demonstrate a record of reliable attendance and punctuality.

WORKING CONDITIONS

Work Environment

• The noise level in the work environment is usually moderate to loud based on patient volume.
• As a result of high patient and call volume, this position experiences stressors that come along with a fast-paced environment.
• Must be able to commute to the Tigard Administrative office at least once weekly or as agreed upon by management.
• Must be able to commute to NHC Primary Care Clinic locations for prescheduled patient appointments.
• While performing the duties of this job, the employee may be exposed to toxic chemicals or blood borne pathogens.

Physical Demands

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

• Regularly sit while working on the computer; use hands and fingers to handle, control or feel objects tools or controls; repeat the same movements when entering data; ability to differentiate between colors, shades, and brightness; read from a computer screen for extended periods of time.
• Occasionally stand and walk around the office to gather supplies, use office equipment, or collaborate with patients or employees.
• Occasionally stand, stoop and lift or move objects, equipment and supplies weighing approximately 20-25 pounds up to 40-50 pounds.
• Speak clearly so listeners can understand.
• Hear and understand the speech of another person.

Neighborhood Health Center Employment Offers are contingent on successful completion of reference checks, background checks, drug screening for illegal substances, Tuberculosis, and any position specific credentialing or licensure requirements.