Mahec

Care Manager, Home Health RN

Asheville, NC

JOB SUMMARY:

The Care Manager, Home Health RN is a specialized Mobile Integrated Healthcare Provider that operates in an expanded role to provide an array of routine and advanced health services to underserved and/or medically fragile patient populations. The role is responsible for provision of care in the patient's home setting by using assessment, planning, implementation, and evaluation techniques in accordance with the policies, protocols, and procedures and under the supervision of the patient referring provider. They will demonstrate sensitivity to needs of culturally diverse populations by providing appropriate sound judgement in a professional manner to coordinate care, remove barriers in accessing and appropriately utilizing health services.

The role is supervised by the Manager of Care Management and serves as a member of a multi-disciplinary care team comprised of Physicians, PA’s, Nurses, Pharmacists, Care Managers, Care Navigators, Behavioral Health Professionals, Respiratory Therapists, and other specialists. This role works collaboratively with the patient and stakeholders to assist in identifying and addressing gaps in the patient’s care, access to care, transitions of care, patient safety and to enhance their overall resiliency and quality of life. The role serves as an educator and coordinator for the patients, their families and for the community in ensuring the highest possible health equity.

SPECIFIC RESPONSIBILITIES:

Assists patients primarily in their place of residence with navigating transitions of care, accessing care, medication reconciliation and health promotion through understanding of and participation in their care plan.
Conducts patient visits that meet MAHEC guidelines.
Coordinates arrival to scheduled patient visits with pre-notification of patient and arrives at agreed upon time.
Promotes patient safety in all aspects of patient care environment.
Documents and reports all findings as requested in EHR, care management platform and data collection software.
Conducts visits as scheduled to complete assessments and follow up
Works as part of multidisciplinary care team
Interacts with physicians, care managers, care navigators, social workers or other referring professionals to report findings and assist in connecting patients with services.
Ensure information is communicated in a timely manner to all members of care team.
Provides basic and advanced level care based on a combination of referring physician orders and treatment protocols, procedures, policies and medications approved by the licensing board.
Supports Medication Review and Reconciliation
Obtains necessary tests and evaluation including but not limited to 12 and 15 Lead EKG, Pulse Oximetry, SP and SP Met, Blood Glucose, lab draws, pulmonary function tests and fetal heart tones based on provider orders and follows Mission Health System guidelines pertaining to sample integrity, handling, labeling and delivery to the lab.
Facilitate and assists with telehealth visits
Completes other testing and screenings as directed by the physician or care manager responsible.
Communicates abnormal findings to the responsible care manager and/or Physician in a timely manner.
Initiates 911 and begins initial BLS and ALS treatment and monitoring of patients deemed unstable and requiring transport to definitive care.
Interprofessional and Person-Centered Planning to determine specific objectives, goals and actions designed to meet the patient's needs as identified through the assessment process. The plan should be action oriented and time specific.
Provides patient centered care and support of care plan
Collaborates with key professionals (Physicians, Advanced Practice providers, Nursing staff, Social Workers, Care Managers, Care Navigators, Palliative Care, Wound Care, etc.) to formulate patient's plan of care.
Strategizes with the interdisciplinary care team to provide the safest, most cost -effective plan of care for post hospitalization, prevention, and discharge transition

This role description is a general description of the essential job functions. It is not intended to describe all the duties the Care Manager, Home Health RN may perform.

KEY COMPETENCIES:

Communication Skills

Effectively and respectably communicate with other individuals, whether it be a colleague, patient, or patient’s family member and appropriately enumerate information in a manner easily understood by all parties. We do this to foster a culture of understanding between all parties, especially in complex and difficult situations, to ultimately provide the best care possible to our patients and their families.

Decision Making

Ability to make the most appropriate decision in a given situation and then taking the next steps to ensure appropriate and timely completion. This requires conflict resolution skills, critical thinking skills, confidence in your ability to make the right decision in most situations. This also includes ability to prioritize your workday appropriately to ensure the most important tasks are completed on time.

HealthCare Knowledge

Having the drive to keep yourself abreast and up to date on the new breakthroughs in your area of expertise and communicating them to the rest of the team, as appropriate. This also includes keeping up with your licensure and yearly training requirements within your area expertise along with MAHEC’s organizational training. Finally, the ability to apply the depth of knowledge maintained and gained through this process in real life scenarios as appropriate.

Interpersonal Skills

Showing the ability to meet difficult situations with grace, professionalism, and understanding. Within your area of expertise, showing respect and showing empathy where appropriate with your colleagues, patients, and their family at all times, even when its most difficult to do so. This is done, in part, by effective listening, being your authentic self, showing responsibility and dependability, and being patient with others.

Organizational Values

Adherence to MAHEC’s founding principles and incorporating them every day. This includes, among others, having integrity and accountability, reverence for other cultures and equitable practices, ability to manage change, and displaying a clear understanding of organizational dynamics. Doing these things creates a culture where people want to do the best for each other and gives personal ownership towards the goal of helping people in their time of need.

Problem Solving

Having an analytical mind and ability to work autonomously to solve complex problems that may arise. The wherewithal to think logically through a difficult problem and come to an appropriate resolution for a given issue. This helps to drive continuous improvement by thinking through where we can improve in a novel way. Measures success by understanding where we are currently and where we want to go and then applying those new ideas to affect positive change.

SPECIFIED SKILLS

COMPUTER
- Excellent skills in Microsoft Office including Word, Excel, PowerPoint, and database applications required.
- Must be competent with virtual (email, Webex, Zoom, Microsoft TEAMS etc.) communication, Electronic Health Record (EHR) systems and Care Management/Coordination systems.
FOREIGN LANGUAGE
- Spanish speaking skills preferred.

PHYSICAL DEMANDS

Light - Moderate energy level: Lift and carry 25 - 35 lbs, Push/Pull 50 - 100 lbs (empty bed, stretcher, etc.)
Frequent (34 - 66% of Workday)

SUPERVISORY RESPONSIBILITIES:

EDUCATION AND EXPERIENCE

MINIMUM REQUIREMENTS:
- Registered Nurse
- Two (2) years of experience as a Registered Nurse and at least one (1) year of home health nursing experience.

REQUIRED LICENSES:

Currently licensed by the North Carolina Board of Nursing as a Registered Nurse.
Valid NC Driver’s License
Current CPR certification

SCHEDULE:

Regular attendance on-site is an essential function of this position. Typical business hours are Monday – Friday, 8:00 am to 5:00 pm (or flexed to best meet the needs of the clients and/or the Division); 40 hours per workweek; weekend, holiday, or evening coverage is occasionally required. Work hours will need to be flexible in order to respond to special work assignments, or evening activities, as requested by the team leader.

POSITION COMPENSATION:

$74,600, full time + full benefits

At MAHEC, we strive to equip all team members with Total Rewards (pay + benefits) to honor their service, support their health, manage their financial security, build their career, and thrive.

All MAHEC employees and learners will be required to receive the Flu vaccine or have an approved exemption.

MAHEC Talent Management is located at 121 Hendersonville Road, Asheville, NC 28803. Equal Opportunity Employer.

MAHEC is a qualifying employer for the Public Service Loan Forgiveness (PSLF) Program. Employees who meet federal requirements may be eligible to have remaining student loan balances forgiven after 10 years of qualifying payments while working full-time at MAHEC.

If you are interested in this role, and you have related experience and qualifications, we encourage you to apply or reach out to AskTalent@mahec.net for support in your job search process. You could be the talent we are seeking for this or other opportunities.