Registered Nurse Care Manager

Community Health Center of Snohomish County offers competitive wages and a comprehensive benefits package designed to address health, time off, retirement and career-advancement needs.  Benefits available include health insurance (medical/dental/vision), up to 160 hours of vacation time pro-rated by FTE every 12 months, paid sick leave, 10-paid holidays, 403(b) Safe Harbor retirement plan with employer match, disability and life insurance, and more!  We also offer $0.75/hour for those who test proficiently in a second language.

Job Summary

The Registered Nurse Care Manager position is responsible for coordinating transitions of case for patients discharged from the emergency department (ED) and inpatient (IP) settings; outreaching to high ED utilizers and connecting them with available community resources; and supporting disease management efforts. This role provides case coordination that spans age, gender identity, and socio-economic spectrums.

Utilizing a patient-centered case approach this position will support and assist with our population health efforts. Patients will receive support in navigating and coordinating case throughout multiple health care systems and managed care organizations. This role will identify opportunities for improving the quality-of-case delivered, patient outcomes, care gap closures. This position communicates, collaborates and coordinates patient case with multiple CHC Snohomish departments including behavioral health, dental, physical therapy, nutrition, and pharmacy services as well as external agencies such as Housing Authority, food banks, Department of Transportation, etc.

Knowledge, Skills & Abilities

• Reads, speaks, understands and writes proficiently in English.
• Works independently and is self-directed.
• Works effectively in a team environment.
• Organizes, prioritizes, and coordinates multiple activities and tasks.
• Works with initiative, energy and effectiveness in a fast-paced environment.
• Problem-solves with creativity and ingenuity.
• Knowledge of medical terminology.
• Proficiency in the use of Microsoft Office applications; Word, Excel and Outlook.

Education Required

• High school graduate or equivalent and
• Associate’s degree in nursing.

Preferred

• Bachelor’s degree in nursing

Experience

• Clinical experience in an ambulatory or acute-care setting (2-5 years).
• Care Management experience (2-5 years)
• Chronic Disease Management experience in diabetes, hypertension, depression, etc. (2-5 years)
• Passion and experience working with Medicare and Medicaid recipients, underinsured and uninsured populations.
• Experience working with immigrant and refugee populations.
• Experience working with low income and multi-ethnic populations.
• Experience working with minority populations including LGBTQ
• Experience working with high-risk OB patients.
• Healthcare information systems, such as electronic health record and practice management systems experience.
• Experience working transition of case management

Preferred:

• Experience with telephonic nurse triage. (2-5 years)
• Bilingual in one or more of the following: Spanish, Chinese, Vietnamese, Ukrainian, Russian, Arabic.

Credentials

• Registered Nurse license with the State of Washington
• BLS for Healthcare Provider

Mandatory to have/obtain one of the following credentials within the first two years of hire:

• Certified Case Manager Certification (CCMC)
• Accredited CM (ACMA – American Case Management Association)
• Case Coordination and Transition Management (AAACN)

Preferred:

• Ambulatory Case Nursing (AAACN)

Other

• Driver's license with the State of Washington.
• Motor vehicle insurance liability policy, a certificate of deposit, or a liability bond to the required limits.

Job Specific Functions/Performance:

Job Specific Functions/Performance: Transitions of Case and Case Management

1. Applies professional nursing theory within the scope of practice for nurses licensed in the State of Washington
2. Responsible for coordinating transitions of case post emergency department (ED) or in-patient (IP) discharge. Serves as a liaison between in-patient discharge planners, managed care organizations, and primary care providers to ensure the patient is discharged to appropriate case. Completes medication reconciliation post-discharge.
3. Outreaches to high ED utilizers to engage in primary case. Uses a patient centered medical home approach to collaborate with patients regarding specialty case internal and external to the organization.
4. Assures timely documentation of assessments and interventions; uses appropriate coding when applicable.
5. Facilitates case planning, advocacy, and health education. Identifies and coordinates with individuals the patient is already engaged with (i.e., Social Services, Health Homes coordinators, adult living facilities, community paramedics, community health workers, etc.)
6. Supports patients with creative solutions when barriers arise in case plans and establishes individualized goals that optimize patient healthcare outcomes.
7. Meet patients in the community including but not exclusive to: ED, hospital, shelters, and community-based organizations as needed for planning.

Job Specific Functions/Performance: Chronic Condition Management

1. Works to improve the health of patients by providing risk assessments and culturally sensitive patient education in all areas of disease management and preventive health case.
2. Conducts screenings and assessments including: SDOH, PHQ9, GAD7, Falls, AUDIT, ADL assessment, reading literacy, health literacy, and performs environmental assessment if appropriate. Completes disease management assessment using readiness tool.
3. Under the supervision of a primary case provider, assesses, documents, and treats minor illnesses/conditions using established clinic protocols and standing orders.

Job Specific Functions/Performance: Quality Case Gap Closures

1. Utilizes data reports to identify, prioritize and assess patient need.
2. Facilitates diagnostic screenings addressing case gaps, chronic condition management and patient education around disease management and wellness promotion.
3. Collaborates with all members of the ambulatory case team including the Population Health Director to promote quality of case delivery. Assists the Clinical Quality RN Manager in evaluating multidisciplinary process improvement activities related to quality of case and patient outcomes.
4. Maintains patient lists. Tracks and trends outreach results.
5. Participates in process improvement activities including PDSA’s and quality studies.

Job Specific Functions/Performance: Additional

1. Adheres to attendance standards in order to perform the job functions for daily operations and/or continuity of patient case.

CHC is an Equal Employment Opportunity/Affirmative Action Employer (EEO/AA)/At-will employer.