Department Overview:
OHSU Health Services is committed to the ongoing journey of being an anti-racist organization that acknowledges the enduring impacts of historical injustices on health; addresses clinical, social, and structural systems and conditions that undermine health and wellness; strives to become a culturally-proficient workplace that reflects the communities served; and fosters an environment of belonging, respect, and inclusion where everyone feels empowered and safe to bring their full, authentic selves to the work. Change requires individuals at all levels of the organization to be proactive in redistributing resources and power equitably by restructuring policies, clinical and financial strategies, culturally sensitive data analysis and the way data is used. OHSU Health unequivocally expects its staff and leadership to fully support this mission in these efforts.
The Integrated Community Care Manager-RN provides one-site (face-to-face) and telephonic outreach, behavioral health, disease and/or care management, care coordination, care integration, care transition, education, support and navigation to OHSU Health Services Members with the goal of supporting healthy life choices and to reduce long term effects of chronic illness. The Integrated Community Care Manager-RN performs other clinically based activities to assist in the coordination and integration of care between the Member, his/her provider(s), health care facilities, health and behavioral clinics, and community-based healthcare organizations and agencies. The Integrated Community Care Manager-RN enhances the quality of Member management by promoting continuity of care and cost effectiveness through whole person care management, care integration, and care coordination across the continuum of health care services.
Function/Duties of Position:
- Facilitate Health System Integration through cross-site communication and care coordination across the Integrated Delivery System and within the OHSU Health Service Area. Serve as a point of contract across transitions working closely with providers, facility and clinic care managers, and agency case workers to assist Members to navigate a complex healthcare system, as the Member moves across settings and systems. Foster a positive and professional relationship and act as a liaison with internal and external customers to ensure effective working relationships.
- Coordinate care through assessing Members referred for care management services for clinical and psychosocial needs, and develop and implement patient-centered care plans that provide interventions including but not limited to disease management, medication management, and Member education and behavior modification within his/her scope of practice. Perform initial Assessments and initiate Care Plans as required by policy and for IDS Members as required by the contract held between OHSU Health Services and Health Share of Oregon and within the timelines established. Reassessment of Member status and adjustment of care plans completed to meet Member on-going needs and goals of care. Monitor and evaluate services and community-based resources necessary to respond to the Member’s individual healthcare needs.
- Provide Member care coordination and self-management through face-to-face and telephonic outreach, which may include home visits, attending clinic office visits, and interaction with patients being seen in the ED or who are in the hospital. These interventions are intended to allow the opportunity to assess the Member’s ongoing needs and to identify resources that will help ensure the Member is meeting his/her health care goals.Collaborate with OHSU Health Services Member’s medical and healthcare community-based providers (that may include the primary care provider (PCP), specialist providers, behavioral specialists, dental providers, or others that may be indicated) regarding the Member’s treatment needs and plan of care. Serve as a key link between the Member, caregivers and the multi-disciplinary clinical team. The frequency of contact is determined based on the Member’s risk acuity ranking and clinical need.
- Routinely document all Member interactions and Member engagements in the electronic medical record (EMR) to ensure a longitudinal record is maintained of all Member interactions. Collect clinical engagement data and enter into the EMR and/or other indicated database for tracking and metric purposes. Maintain medical record confidentiality at all times through the proper use of computer passwords, maintenance of secure files, adherence to HIPAA guidelines and policies.
- Ensure day-to-day processes are conducted in accordance with nationally accepted standards (NCQA, URAC, and other regulatory standards) and for IDS Members, the contract held between OHSU Health Services and Health Share of Oregon. Participate in quality and performance improvement activities that will look to continually enhance the effectiveness, efficiency and quality of services being provided.
- Utilizes proper telephone and personal etiquette and judicious use of other verbal and written communications, following OHSU and OHSU Health Services policies, procedures and guidelines. Follows OHSU and OHSU Health Services telecommuting policies and procedures as a Member of the field-based staff.
Department Specific Qualifications:
- Ability to assess patient health status, consistent with state licensure scope of practice requirements.
- Able to prioritize and target interventions, consistent with state licensure scope of practice requirements.
- Professional verbal and written communication skills, with the ability to clearly articulate thoughts and ideas.
- Organizational skills with the ability to handle multiple tasks and/or projects at any one time.
- Customer service skills with the ability to interact professionally and effectively with providers, third party payers, physicians, and staff from different departments and/or agencies within and outside OHSU and OHSU Health Services.
- Minimum three (3) years of clinical nursing experience.
- Minimum two (2) years of Case/Care Management experience
Required Qualifications:
- Minimum three (3) years of clinical nursing experience.
- Minimum two (2) years of Case/Care Management experience.
- BSN Graduates: Baccalaureate Degree in Nursing from a program accredited by Commission of Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN) or Commission for Nursing Education Accreditation (CNEA) 30 days before start date.
- ADN Graduates: Associate Degree in Nursing from an accredited program 30 days before the start date.
- Associate degree Nurses required to enroll in BSN program within 3 years of hire and complete within 5 years of hire
- Internal ONA applicants: Associate Degree in Nursing; BSN preferred
- Current, unencumbered Oregon State Registered Nurse License
- BLS at time of hire and must be issued by the American Heart Association (AHA)
- BLS must not expire during orientation
- Must be able to perform the essential functions of the position with or without accommodation
Preferred Qualifications:
- Master’s degree as a Registered Nurse or in a related-health field.
- Prior experience in case management, quality improvement, medical record review, utilization and/or disease management.
- Knowledge and experience working within Epic as the electronic medical record.
- Knowledge of Medicare and Medicaid.
- Knowledge of adult learning and behavior change principles.
- Knowledge of community-based resources.
- Demonstrated skills in motivational and health coaching, patient advocacy, health promotion, disease prevention, patient education and resource management.
- Demonstrates knowledge of NQCA and Case Management guidelines.
- Provides care management services appropriate to the age of the member served – neonate, infant, pediatric, adolescent, adult and geriatric patients based on the principles of growth and development and life stages.
Additional Details:
This position also comes with great benefits! Some highlights include:
- Comprehensive health care plans. Covered 100% for full-time employees and 88% for dependents.
- $25K of term life insurance provided at no cost to the employee
- Two separate above market pension plans to choose from
- Vacation - 192 to 288 hours per year depending on length of service, prorated for part-time
- Sick Leave - 96 hours per year, prorated for part-time
- Holidays - up to 64 holiday hours per calendar year (employees accrue .0308 holiday hours for each hour paid)
- Substantial public transportation discounts (Tri-met and C-Tran)
- Tuition Reimbursement
- Innovative Employee Assistance Program (EAP) including extensive wellness resources
Length of Orientation – Experienced Nurse
- External candidates: OHSU & Nursing New Employee Orientation (NEO) for about a week.
- Either Transition to Practice (TTP) Program Specialty Fellowship/Fellowship Learning Pathway or Orientation experience for 3 days-26 weeks depending on the care area. An employment service agreement may apply.
- TTP Program Specialty Fellowship/Fellowship Learning Pathway details and dates: https://www.ohsu.edu/human-resources/transition-practice-program-rns
1 position available.
Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or aaeo@ohsu.edu.
