Transitions of Care, RN bei AllCare Health

Transitions of Care, RN at AllCare Health with the Population Health department in Grants Pass, Oregon

We Are Seeking Qualified Candidates to Join Our Team!

AllCare Health offers competitive wages, an excellent benefits package including affordable healthcare, 401k retirement, wellness programs, and flexible schedule options.

Summary

This position is responsible for coordinating behavioral, medical, social, and dental health care needs for all AllCare Medicaid, Medicare, and Medicare dual eligible members of all ages during transitions from one health care setting to another, or from home, to or from, a healthcare setting; this includes members with terminal conditions requiring goals of care and advance care planning support, and members planning a future surgery occurrence by performing the following duties.

Essential Duties

1. Assess, plans, implements, coordinates and requests services required to meet member health care needs.  
2. Interacts with the member, family, caregiver, and involved healthcare professionals when Goals of Care cases are determined to exist with the purpose of advocating for member decision making and providing adequate education to support member in understanding which choices are available to them, including periodic re-evaluation of individual and family nursing needs for participants who have a terminal diagnosis and a prognosis of 6 months or less. 
3. Coordinates with receiving facility for planned transitions from any setting to any other setting, or unplanned transitions, such as an emergency department visit leading to a hospital admission. 
4. Acts as an advocate and facilitates collaboration with the interdisciplinary care team (ICT) in order to assist members to develop a knowledge base that will allow self-reliance in coping with chronic illnesses.
5. Conducts thorough planning to determine and document specific objectives, goals, and actions to meet the member’s identified needs, including re-evaluation of the individualized care plan (ICP).  

Job Duties

• Serves as subject matter expert in care coordination and case management interpreting regulatory requirements and coordinates the process to support those requirements.
• Understands and has working knowledge of the regulatory requirements from CMS and OHA regarding the frequency of member interactions during transitions.
• Completes thorough assessments to collect in-depth information about member situations in order to identify their individual needs.
• Develops a comprehensive case management plan based on initial assessment and adjusts as necessary.
• Implements plans by executing and documenting specific interventions, activities and/or tasks that will lead to accomplishing the established goals.
• Organizes, establishes, integrates, updates, modifies and documents the resources necessary to accomplish the goals established in the care management plan.
• Continues to gather information from all relevant sources and documentation and determines the plan’s effectiveness.
• Evaluates the plan at appropriate intervals to determine the care management plan’s effectiveness in reaching the goals and outcomes and modifies as necessary.
• Determines outcomes by measuring the interventions in order to determine the effectiveness of performing case management.  
• Delivers condition specific education in accordance with established standards of care and based on clinical practice guidelines.
• Documents the complete spectrum of patient interaction from a disease specific health assessment to completion of goals.
• Participates regularly in Interdisciplinary Care Team (ICT) meetings regarding complicated cases in progress.
• Seeks out and solicits the help of all health care providers and community agencies associated with the case in order to secure appropriate resources for the member.   
• Maintains caseload of high risk/high cost members having designated chronic conditions, in accordance with department policy. 
• Assesses member learning style and develops a teaching program appropriate to reading and comprehension skills of clients. 
• Helps members choose actions that will bring goals and objectives to completion in a timely manner.
• Collaborates with providers of care to ensure appropriate access to services and follow up on the results of referrals. 
• Assists as needed in quality initiatives for the department.
• Coordinates care needs for the Dual Special Needs Population (DSNP) member to ensure compliance with the Special Needs Model of Care (SNP MOC).
• Prepares for and participates in all required DSNP trainings, education, and member audits.
• Participates in initial, annual, and ongoing trainings.
• Maintains punctual, regular and predictable attendance.    
• Works collaboratively in a team environment with a spirit of cooperation.
• Respectfully takes direction from leadership.
• Meets all required training including those listed in Relias Learning Module System (LMS).
• Other duties as assigned.

Supervisory Responsibilities

This position does not have any supervisory responsibilities. 

Clinical Supervision

• This position provides clinical supervision for assigned clinical personnel and other support staff. 
• Supervision needs will be evaluated based on clinical experience and performance and may be weekly but not less than bi- weekly.
• Acts as preceptor during the onboarding of new hire employees.

Job Requirements

• May require the use of personal vehicle for local travel (subject to mileage reimbursement).

Qualifications

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. 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 duties.

All health care providers who are HIPAA covered entities, whether individuals or organizations, must obtain an NPI number. Under HIPAA, you’re a covered health care provider if you electronically transmit health information in connection with a HIPAA standard transaction, even if you use a business associate to do so. AllCare Health employs staff that are defined under OHA or CMS as health care providers. Positions that are defined as providers include, but are not limited to, Doctors, Nurse Practitioners, Physical Therapists, Traditional Health Workers, and Certified or Qualified Healthcare Interpreters.

All relevant experience can be listed in your resume to perform essential duties of the position including the following: lived, volunteer, professional, or a combination of experience and education.

Education & Experience

• Associates or Bachelor's degree from an accredited university in nursing. 
• Knowledge of behavioral health and psychiatric disability issues, psychological and neuropsychological issues, substance abuse, addiction, wellness and illness prevention, multicultural issues, chronic illness and disability aspects, spirituality as it relates to their health, complementary alternative medicine management, and members in various stages of crisis is preferred. 
• At least two years of experience in case management, disease management, managed care, or homecare coordination. 
• Knowledge of appropriate referrals to QI Committee, Corporate Compliance, Fraud and Abuse, Appeals and Grievances.

Certificates, Licenses and/or Registrations

• Valid Oregon Registered Nurse (RN) licensure. 
• Valid Oregon Driver’s License and vehicle insurance. 
• Completes the National Provider Identifier (NPI) registration within the first 30 days of hire. 
• Current Basic Life Support (BLS) Certification or willingness to be certified within 90 days of hire.
• Current Mental Health First Aid Certification or willingness to be certified within 90 days of hire.
• CCM certification is required or to be obtained within two years of hire date. (Subject to pay increase upon Certification)

Physical Demands & Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this job. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

The employee must occasionally lift and/or move up to 10 pounds. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. The employee is occasionally required to stand; walk and reach with hands and arms. The noise level in the work environment is usually moderate.

• Because of exposure to patient records of all types, the highest standard of patient confidentiality and privacy as established by business policy and HIPAA requirements must be maintained.
• The employee must be able to work onsite for all scheduled shifts.
• The employee must be able to travel locally, as needed.

Company Overview

AllCare Health Website:  https://www.allcarehealth.com.

AllCare Health is incorporated as an Oregon Benefit Corporation and has earned the coveted Certified B Corp® status since 2017. As such, AllCare Health considers its impact on community, society, and the environment in all business decisions. We have long recognized the value in social, economic, and environmental concerns of our employees, customers, and community members. (Learn more about B Corps at https://bcorporation.net/about-b-corps)

AllCare Health headquarters are located in Grants Pass in Southern Oregon on the Rogue River, surrounded by mountains, forests, small farms, and breathtaking views. This thriving and energetic community is ideal for families and outdoor enthusiasts, with a temperate Pacific Northwest climate. We enjoy easy access to outdoor sports and recreation, river rafting, fishing, hiking, biking, wineries, outdoor concerts, the world-famous Ashland Shakespeare Festival, the stunning Oregon coast, magnificent redwood forests, pristine beaches, and much more.

The AllCare Health family of businesses is guided by our corporate principles:

Purpose | Working together with our communities to improve the health and well-being of everyone.

Values | Trust, Innovation, Relationships, and Voice.

Vision | Thriving, Inclusive, and Equitable communities.

Brand Promise | Changing Healthcare to Work for You.

AllCare Health is dedicated to building a diverse and authentic workplace centered in belonging and serving our growing community. If you are excited about this open position but your experience does not align perfectly with every qualification in this post, we encourage you to apply anyway or reach out to our human resources department. You may just be the right candidate for this role or others. 

If you need accommodations, help in the application process, or wish to receive this job announcement in an alternative format, please call 541-471-4106 and ask for Human Resources.

All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sexual orientation, gender identity, sex, age, protected veteran or disabled status, or genetic information.