Job Title:

RN Care Manager

NATURE OF POSITION

Responsible for coordinating medical treatment, including administering assessments, developing care plans, and monitoring medication compliance. Develops relationships with patients to facilitate ongoing care management compliance. Connects patients with social and community support systems for continuation of care. Responsible for analytical and QM/RM support for initiatives and projects including but not limited to data facilitation/problem solving and coordinating the implementation of processes to ensure regulatory compliance. Aids departments and senior management in a professional and timely fashion. Assists the clinic in improving care management processes by providing consultative services that assure a proactive versus reactive approach. Provides oversight of the care management model. Analyzes social determinants of health for populations served. Monitors and leads improvement activities to connect patient resources with patient needs. Leads initiatives to build health equity for populations served. Coordination of external referral sources. Ensures appropriate utilization of healthcare resources to maintain PCMH certification. Assists with conducting and monitoring annual wellness visits (AWV). Creates a pathway for capturing relevant patient conditions to obtain accurate risk scores for individual care planning. Develop, identify, and analyze data and information for organizationalwide CM initiatives. Identifies EHR efficiencies to improve documentation of chronic care management and promote interoperability. Collaborates with the chronic care management program to improve preventive screening rates. Assists providers in meeting quality and efficiency outcomes through coordination of care. Utilizes data to improve efficiency. Coordinates with medical providers and Doctor's Alliance to monitor home health certifications and recertifications for compliance. Support the activities of teams including but not limited to Quality, Infection Control, Pharmacy, Environment of Care, Emergency Preparedness and Specialty ADHOC Committees. Provide and coordinate care management related education for clinic and medical staff. Other duties as assigned.

MINIMUM QUALIFICATIONS

Licensure/Certification/Registration:

Current licensure as a Registered Nurse in the

State of Oklahoma Education:

BSN or higher preferred. Nursing Case Management Certification (CMGT BC) OR related field with a minimum of 5 years of related experience required.

Experience:

Minimum of three (3) years of bedside nursing experience. Experience in care management or population health management preferred. Proven record of achievements and leadership, problem solving, and effective communication skills required.

ORGANIZATION

Exhibits enthusiasm, a positive altitude, and professionalism in the workplace Handles personal conflict and works through it at the lowest possible level (first with party/parties involved, then if necessary, with 3rd party mediation) Is friendly and easy to approach Is neat, clean, wellgroomed, and dresses in accordance to the dress code policy Leaves personal problems out of the workplace Treats all coworkers with dignity and respect Abstains from gossip in the workplace Arrives on time and works through designated hours Completes tasks effectively, accurately and on time Demonstrates little or no absenteeism/follows leave guidelines Follows designated line of support Is flexible, able and willing to respond to unusual jobrelated demands Manages time well Recognizes and assists others in the work of the department, even though the work may be outside of regular duties Shares equally in the workload of the department Works cooperatively with all team members and departments Works independently requesting assistance from supervisor only as needed Abstains from criticizing COFMC, colleagues and supervisors Demonstrates loyalty to COFMC, colleagues and supervisors Demonstrates support of the mission and vision of COFMC Accepts and participates in cross training Takes initiative to identify skill development needs About Central Oklahoma Family Medical Center

OUR MISSION

The mission of The Clinic at Central Oklahoma Family Medical Center is to provide quality, comprehensive, and affordable care that improves the health and well-being of our communities.

OUR VISION

The vision of The Clinic at Central Oklahoma Family Medical Center is to provide a healthcare network that delivers the highest quality of care in our communities. 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