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RN - Complex Care Management Manager

- Fulltime  

RN Complex Care Management Manager

Position Description Summary:

The RN Care Management (CC) Manager reports administratively to the Sr. VP for Clinical Strategy and clinically to the Medical Director of Integrated Care (MDoIC). The position provides clinical leadership and expertise in chronic disease management and care management practices. Provides direct oversight of Population Health (PH) RN staff and assures achievement of individual and team performance and productivity standards. Implements changes to effect continual improvement in services provided. Directly responsible for personnel actions including hiring, training, coaching, evaluating performance, monitoring time and attendance, and scheduling of team members. Monitors work product and division of work between team members to promote staff working at the top of the license. Develops staff in an environment that is motivating. Promotes effective communication between departments and entities, acting as a liaison to facilitate information sharing, collaborative problem solving and adequate provision of services; fosters and maintains collaborative relationships within the population health division and the organization. Knowledgeable of government payer requirements and benefits. Provides staff training to assure they remain compliant with provision of services within a variety of different payer types. Maintains skills in care coordination, disease management and patient transition management to allow for coverage during staffing shortages in the department. Performs other duties as assigned.

Strategies must align with Company's integrated Care Management continuum and complex care strategy, as well as realities of catchment healthcare care systems (physical and behavioral health (MHSUIDD) providers) contractual obligations and work flows. Core competencies include but are not limited to:

· Systems Leadership;

· Member/Member centered care;

· Evidence based best practices;

· Informatics; and

· Quality improvement.

This position may work with staff, members and family members as well as community stakeholders.

Note: This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of the Company. The individual filling this position shall also sign a confidentiality statement as an employee of the Company.

Essential Duties and Responsibilities: List in order of importance and Percentages equal to 100%

40%- Management:

The manager will provide supervision to CCMRN Team by observing and monitoring paperwork/documentation/data/reports to ensure that RN Complex Care Management activities are carried out within the Vaya Health catchment area in an effective manner. Participate in the development and validation of data and reporting projects relative to RN Complex Care Management activities. Work in collaboration with Complex Care Management and Care Management Strategy leadership team to identify, develop and implement ongoing complex care improvement. Provide coaching to supervisors and employees to ensure continuous improvement of performance in meeting the needs of members, Vaya Health and community partners. Conduct performance reviews as required and conduct employee trainings to include but not limited to policies and procedures and service definitions, etc.

30% Managed Care Treatment Planning Care Management:

The Manager will ensure that teams have knowledge of duties described below and carry out these duties by providing direct supervision. The Manager may provide coverage in situations that require additional support such as staff shortages or an elevated need for services.

Oversight activities include but not limited to the following:

· Team compliance with Division of Medical Assistance and Division of MHDDSAS Contract with specific emphasis on Care Management roles and responsibilities.

· Team compliance with Complex Care and Care Management Continuum and Vaya policies and procedures.

· Team Risk Management- Proactively ensures individuals identified as a Special Needs enrollee that have treatment needs or require regular monitoring have a Behavioral Health Clinical Home and a Medical Home are assigned and receives outreach in a timely way.

· Ensures through supervision and in person CCMRN skill observation, member education regarding chronic or acute conditions, medication management, and care planning (including how to avoid a medical crisis).

· Ensures person centered principles are utilized by the CCMRN and the team in care planning activities for individuals through fidelity reviews or other CCMRN quality oversight processes.

· Provides support to CCMRN in addressing barriers to care for members through convening key providers and others to address needs of the individual or populations at the individual or system level.

· Proactively works with CCMRN team to identify gaps in services and intervenes to ensure that the individuals and specialty populations receive appropriate care.

· Uses data, chart review and supervision to measures results of intervention and treatment, including reduction in high risk events and inappropriate service utilization.

· Ensures that CCMRN services for the individual are coordinated across the Company system and with other healthcare and social determinant systems.

· Appropriately escalates high-risk scenarios to appropriate leadership. High risk can involve Health & Safety of an individuals served, staff or organizational risk.

· Understand the role of and collaborate with PH Division Teams re routine care planning, discharge planning teams, transitional care plans, educating staff and members regarding network services and supports with consideration of medical necessity, funding eligibility and appropriateness of recommendations relative to person-centered, recovery principles and known best/appropriate practice.

· Ensures CCMRN Team identifies and communicates gaps in care related to network adequacy to Network Department for healthcare needs; coordinates with FastTrack process; notifies Company Network of provider contractual concerns or through established process if quality of care or health and safety concerns.

· Ensure CCMRN Team notifies and updates assigned provider if currently engaged; provides support to the CCM if provider does not engage or follow up appropriately.

· Participate in the development and implementation of best practice complex care and Care Management strategies as identified by Vaya Health; and

· Provide proactive and clear supervision supported by data to ensure individuals and teams are meeting departmental and organizational benchmarks.

· Collaborate with key stakeholders, network providers, and non-network providers with particular attention to primary care, health departments, and healthcare systems.

25% Collaboration:

The Manager will ensure team supervisors and teams to ensure organizational and community partner collaboration. This position will interface with key stakeholders and is responsible for understanding Company organizational goals, initiatives and requirements in order to effectively communicate and facilitate collaborative partnerships. This position is also expected to provide information from key stakeholder interactions to the appropriate departments and teams to improve the care continuum for


Other duties as assigned.

Supervisory Responsibilities:

Population Health RN Team.

This position supervises their team by observing and monitoring paperwork/documentation to ensure that Complex Care Management activities are carried out within the Vaya Health catchment area in an effective manner. The RN CCM Manager will provide coaching to employees to ensure continuous improvement of performance in meeting the needs of members and communities. Will conduct performance reviews as required and conduct employee trainings to include but not limited to policies and procedures and service definitions. The Manager will work with employee to mediate dissatisfaction within the community.


Education and Experience:

An RN degree in nursing and considerable experience in behavioral health, or equivalent combination of education and experience are required.

Mental/Physical Demands:

Person in this position is required to have close visual acuity to perform activities that include viewing a computer terminal; and extensive reading. Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers. Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.

Knowledge, Skills and Abilities:

Thorough knowledge of community-based programs and eligibility criteria pertaining behavioral health, IDD and other healthcare programs; preference for Basic Life Saving certification, thorough knowledge of the policies and practices of case management/Care Management; skill in dealing with members and their families in a tactful manner; skill in the use of personal computers, related software applications, hardware and peripheral equipment; ability to maintain accurate records and files; ability to review and analyze data to assure effective and efficient use of resources, ability to communicate ideas effectively in both oral and written formats; ability to maintain the confidentiality of members; ability to establish effective working relationships with associates, members, their families, social workers, medical practices, and the general public. Ability to travel and work with members and their families in office-based, home and/or community settings.

Proficiency in Microsoft Office products (such as Word, Excel, Outlook, PowerPoint, etc.) and Company information system is required.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


Must be licensed as a registered nurse in North Carolina

Driving on Company Business:

This position requires driving a personal vehicle for Vaya Health Business in accordance with 216.02 Travel Reimbursement policy and 302.0 Driver Requirements & Safety Guidelines.

Decision Making/Consequences of Error:

Decisions result in members either receiving or not receiving appropriate services or appropriate referrals for higher-level assistance as needed.