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.

The OHSU Clinical registered nurse (RN) provides compassionate, evidence-based, and efficient care to individuals, families, communities and patient populations. The Clinical RN's care delivery is consistent with the Oregon Nurse Practice Act, the ANA Scope and Standards of Practice, and the ANA Code of Ethics. The Clinical RN demonstrates the professional role obligations of scientist, leader, and knowledge transferor [Onsomble Model of the Professional Role]. Professional accountability enriches the Clinical RN's engagement as a leader in promoting an inter-professional culture of collaborative decision-making, innovation, life-long learning, and teamwork. The Clinical RN exemplifies the principles of a Culture of Safety by committing to a Just Culture, a Reporting Culture, a Learning Culture, and an Engaged Informed Culture.

1. 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.
2. 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 Members individual healthcare needs.
3. 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 Members ongoing needs and to identify resources that will help ensure the Member is meeting his/her health care goals.
4. Collaborate with OHSU Health Services Members 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 Members 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 Members risk acuity ranking and clinical need.
5. 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.
6. 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.
7. 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.

• External applicants - BSN from an accredited school required.
• * Current OHSU employees: BSN preferred*
• Current unencumbered Oregon RN license.
• Attainment of Professional certification as a Case Manager within 24 months of hire.
• BLS at time of hire and must be issued by the American Heart Association (AHA) or Military Training Network branch of AHA (upload documentation with online application)
• BLS must not expire during orientation or probation period, and must have the same expiration date (upload documentation with online application)
• Minimum three (3) years of clinical nursing experience.
• Minimum two (2) years of Case/Care Management experience.
• Must be able to perform the essential functions of the position with otr without accommodation.
  

Job Related Knowledge, Skills and Abilities (Competencies):

• Clinical assessment skills, consistent with state licensure scope of practice.
• 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.
• Strong telephonic communication and interviewing skills.
• Analytical and interpretation skills including departmental, utilization, financial and operations data.
• Decision-making skills with the ability to investigate and weigh alternatives, integrate data, and select the most appropriate course of action that meets the best-interest needs of the member and provides the greatest benefit to the organization.
• Creative- and critical-thinking skills with the ability to consider new ideas that will lead to process and team improvements.
• Time management skills with the ability to prioritize and schedule daily activities for the most efficient use of time.
• Problem-solving skills with the ability to look for the root cause of issues and implementable, workable solutions.
• Interpersonal skills with the ability to work in a fast-paced environment with the ability to participate as an independent contributor with little direct supervision or as an active team member depending on the circumstance or need.
• Attention to detail and a track record of producing high-quality and accurate work that reflects well on the organization.
• Knowledge and experience in working with computer systems and electronic medical records.
• Able to travel within the tri-county area with an active and unrestricted drivers license, reliable transportation and active automobile insurance coverage. OSHA compliant home workspace, committed to maintaining the confidentiality of member protected health information in accordance with HIPAA guidelines, and OHSU and OHSU Health guidelines and policies.

• Current OHSU employees: BSN preferred
• Masters degree as a Registered Nurse or in a related-health field.
• Professional certification (ACM, CCM, CCP) at time of hire.
• Prior experience in case management, quality improvement, medical record review, utilization and/or disease management.

Preferred:Job Related Knowledge, Skills and Abilities (Competencies):

• 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.

Orientation period: Typically on-boarding for the position is 4-6 weeks, depends on the level of past experience of the individual.

This is now a Telework opportunity.

*Bonus Disclaimer: current OHSU, Adventist and Hillsboro Medical Center employees are not eligible