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AMH+ RN Care Manager
R-1421 Job Description: The RNCM manages a panel of rising and high intensity members to support integrated chronic disease and behavioral health care for the members. The RNCM collaborates with members to create a care plan and oversees progress to the plan, frequently reassessing needs, coordinating with providers and specialized resources, and partnering closely with the Community Health Partner to build trust and demonstrate advocacy. Responsibilities:
- Receive members from the engagement and care team, clearly communicating program expectations, including duration and goals.
- Complete self-efficacy and condition-specific screeners during the assessment and intake phase, along with behavioral health screeners like PHQ-9, GAD-7, AUDIT, and DAST-10 to identify behavioral health needs.
- Conduct in-person clinical examinations when appropriate and collaborate with care team members to determine member placement in programs of varying intensity.
- Prepare for and actively participate in case conferences, leading discussions when necessary.
- Develop a care plan in collaboration with the member and address social needs with the support of the Community Health Partner.
- Conduct regular clinical visits and follow-ups per program guidelines, monitoring routine therapeutic interventions and addressing member needs promptly.
- Collaborate with the care team to support a panel of assigned members, providing clinical assistance in health maintenance, chronic disease management, and co-occurring psychiatric disorder support.
- Perform medication reconciliation, administration, compliance, and education as part of member care.
- Address quality gaps prioritized by the contracted company and ensure thorough chart documentation and coding (ICD or CPT) to validate gap closures.
- Utilize care facilitation tools, electronic health records, and scheduling platforms to gather data, document member interactions, organize information, track tasks, and communicate with team members and community resources.
- Support members in achieving their care plan goals through coordinated and comprehensive care efforts.
- 3+ Years of Nursing experience
- Graduate of an accredited school of nursing (R.N.)
