Acute Transition Care Management RN/Registered Nurse Manager Statewide

LOCATION:
Remote - must reside in North Carolina or within 40 miles of the NC border.
Must have the ability to travel statewide throughout Vaya's catchment area as needed.

GENERAL STATEMENT OF JOB

The Acute Transition Care Management (ATCM), Registered Nurse (RN) Manager reports to the Integrated Care Management Director.
This position is responsible to provide clinical leadership and direct oversight of Acute Transition Care Management, RN staff who provide proactive intervention and coordination of care to members and recipients of Vaya's Health plan who are receiving care in an inpatient community hospital or emergency department for physical health reasons.
The ATCM, RN Manager provides oversight of the ATCM, RN to ensure appropriate transitional care management is performed.
This position ensure the ATCM RN works with the member and care team to identify and alleviate inappropriate levels of care or care gaps through assessment, multidisciplinary team care planning, linkage and/or coordination of services needed by the member across the MH, SU, intellectual/ developmental disability ("I/DD"), traumatic brain injury ("TBI") physical health, pharmacy, long-term services and supports ("LTSS") and unmet health-related resource needs networks.
The ATCM, RN Manager maintains skills in care management and care coordination to allow for coverage during staffing shortages in the department.
This position provides oversight of ATCM, RN job duties and responsibilities and utilizes licensed clinical knowledge and skills to assess needs, inform care planning development, provide clinical consultation, and offer recommendations for appropriate care as needed to support the ATCM RN team.
The Acute Transition Care Management, RN Manager implements process improvement interventions and staff development activities in an environment that is motivating while ensuring achievement of individual and team performance and monitors productivity standards.
This position also works with other Vaya staff, members, relatives, caregivers/ natural supports, providers, and community stakeholders.
Performs other duties as assigned.

As further described below, essential job functions of the ATCM RN, Manager includes, but may not be limited to:

• Utilization of and proficiency with Vaya's Care Management software platform/ administrative health record ("AHR")
• Outreach and engagement
• Compliance with HIPAA (Health Insurance Portability and Accountability) requirements, including Authorization for Release of Information ("ROI") practices
• Performing Health Risk Assessments (HRA):
  a comprehensive bio-psycho-social assessment addressing social determinants of health, mental health history and needs, physical health history and needs, activities of daily living, access to resources, and other areas to ensure a whole person approach to care
• Adherence to Medication List and Continuity of Care processes
• Participation in interdisciplinary care team meetings, comprehensive care planning, and ongoing care management
• Transitional Care Management, Diversion from institutional placement

• Effectively implement organizational priorities, quality initiatives and programs through the ATCM RN Team;
• Provide proactive and clear supervision supported by data to ensure ATCM RN and teams are meeting departmental and organizational benchmarks;
• Supervise the ATCM, RN Team by observing and monitoring paperwork/ documentation/ data/ reports to ensure transitional care management/care coordination activities are carried out within the Vaya Health catchment area in an effective manner;
• Participate in the development and validation of data reports and reporting projects relative to ATCM, RN activities;
• Provide oversight of ATCM, RN Team to support appropriate, collaborative, integrated care and transition planning (hospital care management/coordination teams) for Vaya members eligible for Tailored Care Management (TCM), or Care Coordination (CC), who are transitioning from physical health inpatient settings to another level of care.
• Ensure ATCM, RN Team has knowledge of team duties, departmental expectations, agency requirements and organizational functions, including but not limited to network options, level of care, medical necessity criteria, benefit plans, etc;
• Provide minimum monthly supervision to ATCM RN including data review and analysis to support staff and overall team performance; Document supervision notes completely, typed with action and follow up items clearly defined.
  Ensure supervision minutes are created and readily accessible and team members' supervision minutes meet minimum departmental standards;
• Conduct performance reviews as required and conduct employee trainings, to include but not limited to; policies and procedures and service definitions, etc.
• Coach supervisors and employees to ensure continuous improvement of performance in meeting the needs of members, Vaya Health and community partners.
  Conducts trainings on relevant clinical physical health care management topics;
• Provide high level oversight for member's transitioning to a Skilled Nursing Facility (SNF) due to complexity of cases and to ensure timely transition to SNF;
• Work with Director of Integrated Care Management, RN CM Managers and other clinical leadership to design, implement and monitor CM dept integrated care goals and objectives.
• Utilize data, dashboards, and outcomes metrics to monitor individual and overall team performance and population outcomes.
  
• Participate in the development and implementation of best practice complex care strategies as identified by Vaya Health.

• Ensure team compliance with Continuity of Care and Tailored Care Management Continuum and Vaya policies and procedures.
  Ensures person-centered principles are utilized by the ATCM, RN and the team in transitional care planning activities for individuals through fidelity reviews or other ATCM, RN quality oversight processes.
  
• Provide support to ATCM, RN in addressing barriers to care for members through convening key providers and others to address needs of the individual or populations at the individual or system level;
• Proactively works with ATCM, RN team to identify gaps in services and intervenes to ensure that the individuals and specialty populations receive appropriate care;
• Ensure team works in an integrated care team including, but not limited to, doctor and pharmacist along with the member to address needs and goals in the most effective way ensuring that member/LRP could decide who they want involved;
• Ensure ATCM RN uses clinical skills and expertise to review clinical assessments and discharge plans conducted by providers to ensure all areas of the member's needs are addres.