RN Complex Care Manager

  • Aids Healthcare Foundation
  • Fort Lauderdale, FL , United States
  • Jan 05, 2018
Full time Registered Nurse

Job Description

AMAZING INDIVIDUALS WORKING FOR POSITIVE PEOPLE at AIDS Healthcare Foundation!

 

Does the idea of doing something that really makes a difference in people’s lives while being well-compensated intrigue you? Are you looking to work for an organization that encourages growth and success from each and every one of its employees?

 

If so, AIDS Healthcare Foundation is the place for you!

 

Founded in 1987, AIDS Healthcare Foundation is the largest specialized provider of HIV/AIDS medical care in the nation. Our mission is to provide cutting edge medicine and advocacy, regardless of ability to pay. Through our healthcare centers, pharmacies, health plan, research and other activities, AHF provides access to the latest HIV treatments for all who need them.

  

AHF’s core values are to be:

 

• Patient-Centered

• Value Employees

• Respect for Diversity

• Nimble

• Fight for What’s Right

 

 

STILL INTERESTED? Please continue!

 

Summary

The RN Complex Care Manager (RNCCM) is responsible for projecting and integrating the mission

and core values of the organization in the provision of care management services to members of

PHP and PHC health plans.

 

Key responsibilities include the intense and complex care management of members meeting the criteria of catastrophic needs. These will include those members identified with more than one ER visit in a quarter, all cause readmissions to acute hospitals, transplant work-up/wait list/follow up, skilled nursing facility stays greater than 14 days, high utilization of outpatient/home health services, substance dependence, diagnosed mental health disorders, chronic homelessness and a history of non-compliance to provider appointments/ARV regimens. The RNCCM will provide culturally and linguistically sensitive complex care management services to the HIV/AIDS special needs population enrolled in PHP and PHC health plans under the supervision of the UM/CM Manager. The RNCCM contributes to successful patient outcomes by designing and implementing a comprehensive targeted individualized care plan that addresses member needs and necessary interventions that stabilize the member’s condition and decreases the over-utilization of services. The RNCCM collaborates with the Chronic Care Team in order to transition the member to the appropriate level of care when the acute and/or catastrophic need has been stabilized or eliminated. The RNCCM participates in activities that increase understanding of the communities served and assures members have access to and knowledge of their health plan benefits, community benefits, treatment and medication adherence plan. 

 
Responsibilities:

Duties and Responsibilities include but are not limited to:

•    Visitation of hospitalized members at least once a week during the member’s hospitalization in order to:
•    Provide member and designated care giver education to assist the member in better management of the diagnosed medical condition.  
•    Collaborate with the hospital, consulted physicians and the primary care physician (PCP) in developing a discharge and transition plan that:
 •   Avoids the negative consequence of fragmented care
•     Eliminates the duplication of services
 •   Resolves inappropriate care recommendations
•   Provides post discharge education that reduces confusion, resolves conflicting care recommendations, educates member/care giver on signs and symptoms for immediate notification of RNCCM or PCP
•  Avoids medication errors through pre-admission, concurrent and post hospitalization medication reconciliation and member education
•   Empowers member and care giver(s) to be active in care decisions and execution of the transition plan
•    Collaborates with PCPs and external network PCPs, the Chronic Care Team and other practitioners to ensure care is coordinated and integrated into the individualized care plan (ICP).
•    Prepares a personal health record check list with the member that includes dates of follow up appointments, instructions, warning signs, critical activities, medication list, and member personal notes. 
•    Makes home visits to ensure the member and care giver pre-discharge preparation and post discharge transition plan is in place and the self-management support is adequate to meet the goals of the transition plan to prevent readmission.
•    Assures that transition plan and self management goals are realistic.
•    Remains accessible to member and care giver to address concerns and answer questions. Returns phone calls within 1 hour of receipt during working hours.
•    Facilitates communication across venues of care by coaching patients and their caregivers to be advocates for ensuring that their needs are met across settings. 
•    Assures that member is knowledgeable about comorbidity exacerbations and how to respond.  Facilitates PCP urgent care visit according to member needs.
•    Instructs member and care-giver on care access and advice for after hours, weekend and holidays. 
•    Interacts with assigned members weekly: e.g., daily phone calls, house calls, monitoring checks, etc.
•    Communicates member progress and adjustment of ICP on a frequent basis with assigned PCP.  Provide written progress reports in the first 30 days post discharge on a weekly basis.
•    Collaborate with ASOs, Waiver Providers and other Community Organizations as necessary to ensure appropriate access to service and follow up on the results to such referrals.
•    Responsible to manage and coordinate care for an assigned population of members who have been shown to be the highest severity level and highest risk. This includes but are not limited to high utilization members, members with documented frequent ER usage, frequent admissions and readmissions within 30 days  
•    Completes assessments, re-assessments and care coordination for members assigned.
•    With the member, establishes patient centered long term and short term goals for care and management of the member’s disease state with the focus on the intense case management of complex issues and multiple comorbidities. 
•    With the input of the member, family and medical team creates an appropriate and timely individualized care plan to assist the member to achieve the established goals.
•    Maintains current knowledge of plan benefit structure, policies and procedures related to authorization of services; and is adept at creating a wrap around solution to address member’s needs using intense, complex care management, appropriate plan benefits, and available ASO and community resources.
•    Works to deliver these intense, complex care management services in an efficient and cost effective manner, and analyzes medical records and applies medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests
•    Reviews member status on a continual basis for appropriate assignment to the catastrophic care designation and collaborates with RN Care Team Manager when assignment changes occur.  
•    Communicates the care plan to the PCP, member and others in the Health Home.
•    Revises the ICP to reflect changes in the member’s health and needs, at a minimum, following hospitalization of the member, or following the annual re-assessment.
•    Meets with members in all care settings to complete assessments and other contacts, as necessary.
•    Works to re-engage the member following hospital admissions and emergency room use through intense care management, education, coordination of care, follow-up appointments and arrangement of transportation as needed.
•    Monitors the appropriate use of outpatient ancillary services, medication adherence, compliance to PCP visit schedules and results of lab work.
•    Provides daily support to patient in the form of calls, follow-up visits, collaboration with providers and family in all care settings. .
•    Provides health education regarding disease process, medications, medication adherence, community resources and benefits.
•    Collaborates with AIDS Service Organizations (ASOs) and other community resources, as necessary, to ensure appropriate access to care and services.
•    Maintains current clinical knowledge of HIV/AIDS medications and treatment regimens.
•    Maintains at least the minimum performance and productivity standards.
•    Completes a minimum of three recommended AIDS related in-services, trainings or conferences per year.
•    Reports urgent member issues and barriers to care to the Primary Care Provider and the Manager or Director of UM/CM, as appropriate.
•    Advocates for member needs with providers in all care settings, 
•    Obtains and maintains HIV/AIDS disease/treatment general knowledge proficiency
•    Reports all complaints and grievances per grievance policy.
•    Other duties as assigned to ensure team goals are met.

Management Responsibilities
Participates in weekly MCO Clinical and Utilization Rounds. 
Collaborates with the plan Medical Director, Manager and Director of Utilization and Case Management, on all aspects of member care, including but not limited to medical management, complaints/grievances, utilization of services and social issues.

 

 
Qualifications:

 

To perform this job successfully, an individual must be able to satisfactorily perform the essential duties. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience
•    Graduate of an accredited RN program required; BSN or MSN preferred
•    At least five years of clinical experience and three years of case management, community, home health or hospice nursing preferred. CCM and/or ACRN certification desired.
•    Managed Care experience a plus with knowledge of Medicare and Medicaid regulations.
•    Certified Case Manager (CCM) or eligible for certification with one year of employment.
•    Certified AIDS Care RN (ACRN) or eligible for ANAC certification within two years of employment

Computer/Software Skills & Abilities
To perform this job successfully, an individual should have adequate typing skills and basic knowledge of business software, including but not limited to: MS Word, MS Excel, MS Access data base input to pre-designed forms, Internet Explorer and MS Outlook.  
        
Language Skills
•    Excellent written and verbal communication skills.
•    Ability to read, analyze, and interpret AHF documents, policies, procedures, publications, and other documents.
•    Ability to respond effectively to sensitive inquiries or issues  
•    Skilled in motivational interviewing techniques to engage member in the plan of care
•    Ability to effectively present information and respond to questions from groups of peers, superiors, clients, customers, and the general public.
•    Bilingual Spanish and/or Creole a plus.

Reasoning Ability
•    Ability to define problems, collect data, establish facts, and draw valid conclusions and express same verbally and/or in writing
•    Ability to interpret and follow a flow diagram
•    Ability to apply the nursing process to assessment, care planning and patient management
•    Ability to prioritize tasks and delegate to the appropriate staff 
•    Ability to interpret a variety of technical instructions in mathematical or diagram format including abstract and concrete variables

Other Skills & Abilities/Qualifications
•    Excellent organizational skills
•    Ability to successfully work with various levels of professional and non-professional staff
•    Must be able to work independently and as a leader or member of a team
•    Knowledge of HIV/AIDS, related medical and patient care issues and concerns in diverse populations

Certificates, Licenses and Registrations
•    Unrestricted Registered Nurse licensed by the State of Florida
•    Baccalaureate or Advanced Nursing Degree preferred 
•    Certification in case management and HIV/AIDS preferred 
•    Valid Florida Driver’s License with proof of automobile liability insurance 

Travel 
Over 80% Local travel. Home and field based position with daily local travel to health care centers, inpatient facilities, physician offices, member homes, AHF Managed Care and Corporate offices. *Travel is specific to the assigned county.