Health Services Care Manager – RN:

Job Purpose:

The Health Services Care Manager carries out the care management process with clients by completing assessments, care planning, plan implementation, and monitoring. This requires that the Care Manager visits clients, communicates with clients and family members, and works collaboratively with resource providers, both inter-and-intra-agency. This work is done in support of Enable’s mission and within the guidelines of its policies and procedures. Health Care Manager collaborates with Health Services Care Coordinator to ensure that clients’ needs are addressed, and supportive documentation is completed in a timely manner.

Responsibilities

Outreach Activities

Work within the community designed to identify at risk persons likely to qualify for and need health, wellness, and social support services, as well as care management. Additionally plan, organize, and facilitate health fairs in underserved areas. Attend COA and Advisory meetings in person and virtual.

Screening

Conduct a preliminary assessment of the client’s circumstances and resources. This assessment may be by phone or in person. During Covid-19 most of the assessments were done over the phone in order not to spend too much time with the client for risk of infection.

Home Visits

• Perform home visits to conduct assessments of clients for safety, support systems, physical and emotional well-being, financial stability, substance abuse, etc., in accordance with and support of Enable’s mission to provide monitoring of individual/familial situations and provide appropriate and effective intervention for their well-being if needed
• It focuses on physical health, mental functioning, ability to perform activities of daily living, social supports, physical environment, and financial resources. Also, look at their medications to educate client on interactions and side effects of the medications.

Care Planning

• Use the information collected during the assessment process to develop a plan.
• Care planning requires clinical judgment, creativity, sensitivity, and knowledge of community resources.
• Care managers consider the willingness and availability of informal caregivers to provide care, attempting to establish a balance between formal and informal services.
• Clients and caregivers (where available) participate in developing the care plan.
• Care planning is a key resource allocation process and a critical care management function.
• We follow up with the client and family to see if their needs were met.

Service Arrangement

• Contacting and/or put the client in touch with both formal and informal providers to arrange services specified in the care plan. This may include but not limited to support provided to client during application process for food assistance, voucher assistance, transportation needs, living wills/wills/POA, financial assistance, etc.
• Providing case/care management and maintaining client relationships by providing support, psychoeducation regarding medical issues, and linking clients to community resources, etc.

Ongoing Monitoring

• Provide case management and care coordination; building effective client relationships; assisting persons with processing information and resolving personal issues; providing education and linking clients to local community resources; managing crises, etc.
• Follow up with the client to determine if the desired outcomes were achieved
• Modify the care plan as needed.
• Provide other community resources if needed.

Documentation

• Provide assistance in compiling monthly reports and make available to the Executive Director, per guidelines provided
• Maintain updated records and client records that support Enable’s need to demonstrate the efficacy of the agency’s health services to funding providers and the community at large.
• Collaborate with the Enable staff to update the agency’s, especially Safety Net’s, policies, and operating procedures, as needed.
• Maintain adequate records that support Enable’s need to demonstrate the efficacy of the agency’s Health services to funding providers, and to the community at large.

Outcome Measures

• Complete outcome measurement tools that demonstrate Enable’s ability to carry out its mission and support the documentation requirements from funding providers.
• Orient, manage and supervise student interns, volunteers and others per agency policies and procedures and/or within academic curriculum guidelines
• Collaborate with other Enable staff members, and with outside resources, to achieve the goals established for each client.
• Respond to inquiry calls; assist each caller in a professional and compassionate manner and link to community resources.
• Communicate with referrers and other community resources as necessary to improve knowledge of community-wide services to better serve Enable’s population.
• Meet regularly with the Executive Director to review client status and to ensure that services are being provided as planned.
• Contribute to staff meetings in a productive manner and participate in community-based meetings and/or elder care events as requested, to develop relationships with referrers and other community resources, and for the good of the agency. Make home visits as required by workload, within the scope of this position, and at the direction of the Executive Director.
• Gather necessary data and calculations for Grants Coordinator for major grants, 6-month, and annual reports for funders such as United Way of Madison County, Huntsville Hospital, Alpha Foundation, etc., as directed by Executive Director and/or Grants Coordinator.

Education/Experience

• A qualified licensed Registered Nurse with excellent assessment skills.
• A minimum of 3 years of clinical experience in an outpatient or community-based setting.
• A thorough and demonstrated understanding of care management.
• Experience delivering services to elderly patients/clients.
• Previous work or volunteer experience in a non-profit environment preferred.
• Ability to fully contribute as a member of a team.
• Excellent communication skills.
• Attention to detail, particularly concerning documentation.

Knowledge

• Good computer skills, particularly with File Maker Pro, Microsoft Office, and Mac-OS

Skills

The incumbent must demonstrate the following abilities:

• Effective communication and interpersonal skills
• Successfully manage complex projects; prioritize and handle multiple tasks for multiple projects
• Superior organization and time-management skills
• Strong logic and problem-solving skills
• Exceptional attention-to-detail
• Interact with a diverse group of people
• Work well both independently and in a team environment
• Work well in a fast-paced environment.
• Commitment to CASA’s mission.

Attributes

The incumbent must possess the following personal attributes:

• Creative and open-minded
• Possess a keen business sense
• Honest and trustworthy
• Desire and ability to learn
• Self-motivation
• Strong work ethic
• Likability and Team-Oriented
• Dependable
• Respectful
• Adaptability
• Positive Attitude

Interested Applicants: Submit resume and contact information to info@enablemadisoncounty.org.