LOCATION: Remote - must live in or near Caldwell County, North Carolina. Must have the ability to travel in or near Vaya's region.
GENERAL STATEMENT OF JOB
The Acute Transition Care Manager, Registered Nurse (ATCM, RN) reports to the Acute Transition Care Management, Registered Nurse Manager (ATCM, RN Manager) and is responsible for providing proactive intervention and coordination of care to Vaya Health members and recipients ("members") who are receiving care in an inpatient community hospital or emergency department for physical health reasons to ensure that these individuals receive appropriate transitional care and services. 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, while ensuring existing or new care team members are informed of the transition plan. This position supports and may provide clinical transition planning assistance to community hospitals and tracks individuals discharged from facility settings to ensure they follow up with aftercare services and receive needed assistance to prevent further hospitalization. The ATCM, RN promotes effective cross-organization communication and maintains collaborative relationships within the organization to achieve division objectives. The ATCM, RN maintains skills in care management, care coordination, disease management, and patient transitional care management. This position may work with internal staff, hospital staff, members, guardians/family members, community stakeholders, and others as appropriate to meet the member's transitional needs. Performs other duties as assigned. The ATCM, RN also utilizes licensed clinical knowledge and skills to assess needs, inform transition planning development, provide clinical consultation, and offer recommendations for appropriate care.
ESSENTIAL JOB FUNCTIONS
Essential job functions of the ATCM, RN include, 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
This position is required to meet NC (North Carolina) Residency requirements as defined by the NC Department of Health and Human Services ("NCDHHS" or "Department").
KNOWLEDGE, SKILL & ABILITIES
- Capacity to provide clinical leadership and direct oversight of ATCM, RN staff and ensures achievement of individual and team performance and productivity standards
- Ability to implement process improvement interventions and develop staff in an environment that is motivating
- Exceptional interpersonal skills and ability to represent Vaya in a professional manner
- Ability to take ownership of projects from planning through execution
- Strong attention to detail and superior organizational skills
- Proficiency in Microsoft Office and Vaya systems, to include Excel, data analysis, and secondary research
QUALIFICATIONS & EDUCATION REQUIREMENTS
Associate Degree in Nursing required. Bachelor's Degree in Nursing, Healthcare, or Human Services preferred. Two (2) or more years of experience working directly with individuals with physical health, behavioral health, IDD, or TBI needs. Experience in Medicaid Managed Care preferred.
Licensure/Certification Required:
An active and unencumbered RN license. Must be licensed as a registered nurse in North Carolina.
PHYSICAL REQUIREMENTS:
- Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
- Physical activity in this position includes crouching, reaching, walking, talking, hearing, and repetitive motion of hands, wrists, and fingers.
- Mental concentration is required in all aspects of work.
RESIDENCY REQUIREMENTS: This position is required to reside in North Carolina or within 40 miles of the North Carolina border.
SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.
DEADLINE FOR APPLICATION: Open Until Filled
APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.
Vaya Health is an equal opportunity employer.
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