OverviewM Health Fairview has an immediate opening for an RN Care Coordinator to support the Fairview Partners (FVP) team.This is a 1.0 FTE (80 hours per two week pay period) opening.M Health Fairview offers a competitive benefits package including medical/dental, 401k/403b with employer match, tuition reimbursement, and PTO! For details, please visit our benefits page by clicking here! (https://www.fairview.org/careers/benefits/noncontract)This position will serve Fairview Partners members in the Twin Cities metro area - specifically Minneapolis and surrounding southwest suburbs.Responsibilities Job DescriptionFairview Partners (FVP) provides high intensity care coordination and case management for seniors and other at-risk populations living in a variety of care settings throughout the 11-county metro area. The FVP Nurse (RN) Care Coordinator provides coordination across all settings of care and performs the functions of case management which include, but are not limited to: assessment, care planning, service coordination and referral, transition management, utilization management and quality assurance. The care coordinator promotes holistic, high quality and cost-effective care with the goal of keeping seniors in the most independent care setting possible. Care coordination for the FVP population is delivered via partnerships with managed care organizations (MCO) and must adhere to regulations set forth by the MCOs, the Minnesota Department of Human Services (DHS), the Minnesota Department of Health (MDH) and the Centers for Medicare and Medicaid Services (CMS).Job Expectations:Assessment
Conducts annual Health Risk Assessment (HRA) and scheduled follow-up assessments according to MCO, Minnesota Department of Human Services (DHS) and Centers for Medicare & Medicaid Services (CMS) guidelines
Performs additional clinical assessments specific to the population being served per professional scope of practice and license
Assesses eligibility for State Plan Personal Care Attendant services during HRA, as appropriate; if a licensed public health nurse, may perform assessment independent of HRA
Performs pre-admission screening annually and upon transfer to skilled nursing facilities
Care Planning
Creates person-centered care plan with member including realistic goal-setting and follow-up plan for measuring goal progress
Promotes informed choice of benefits, services and health care providers
Prioritizes member’s safety and risk mitigation
Implementation of care plan via resource referral and communication with interdisciplinary care team
Evaluation of care plan including outcome measures and goal achievement
Coordination of Medicare and Medicaid Benefits & Services
Maintains knowledge of Medicare and Minnesota Medical Assistance health care benefits
Provides case management of Elderly Waiver program benefits and services
Maintains knowledge of long-term services and supports (LTSS) policy and eligibility criteria
Maintains members’ eligibility data in the Minnesota Medicaid Information System (MMIS)
Member of Interdisciplinary Team/Facilitator of Communication
Actively communicates with other care team members
Attends departmental case conferences as requested
Attends care conferences
Convenes interdisciplinary team members, as needed, for members with complex health care needs
Consults with FVP Social Work Care Coordinator for members with complex behavioral or chemical/mental health needs or members needing assistance with financial resources or conservatorship/guardianship
Coordinates with other agencies or professionals involved in members’ care, including but not limited to: waiver program case managers, Mental Health Targeted Case Managers, Adult Protection workers, state Ombudsman representatives and county financial workers
Transition Management:
Actively manages member transitions and communicates across settings to ensure continuity of care
Completes required documentation for transitions of care as required by CMS and DHS
Attends transitional care conferences
Provides discharge follow-up and modification of care plans to ensure members can successfully manage care needs upon return to original care setting
Assists members with planning and resources in transitions to new care levels or living settings
Additional Responsibilities:
Preventative Health Education: Provides education on preventative health measures, as appropriate, for member’s age and health status; promotes managed care health promotion program resources
Chronic disease management and minor triage
On occasion, delegated medical functions, as ordered or prescribed by a licensed health care provider
Mandated Reporting: Reports maltreatment under the Minnesota Vulnerable Adults Act; understands a member’s right to autonomy and self-determination and recognizes reportable risk
Advance Care Planning: Maintains knowledge of advance care planning principles; follows Fairview’s system advance care planning policies and procedures to promote a culture of informed health care decision-making that honors a member’s goals, values and beliefs
Quality: Carries out activities to support the achievement of outcome measures for the Fairview system, Health Plans, DHS and CMS
Additionally, the care coordinator maintains professional boundaries and provides culturally appropriate care. The care coordinator is committed to ongoing professional learning and continually improves his or her practice by attending professional conferences and continuing education activities related to case management and care coordination.Organization Expectations, as applicable:
Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served
Partners with patient care giver in care/decision making.
Communicates in a respective manner.
Ensures a safe, secure environment.
Individualizes plan of care to meet patient needs.
Modifies clinical interventions based on population served.
Provides patient education based on as assessment of learning needs of patient/care giver.
Fulfills all organizational requirements
Completes all required learning relevant to the role
Complies with all relevant laws, regulation and policies
Performs other duties as assigned.
QualificationsRequiredEducationBachelor’s degree in nursing or equivalent: Associate Degree in nursing with two years of experienceExperienceThree to five years of experience in geriatric nursing, public health or care coordination/case management.Strong knowledge of managed care programs, long-term services and supports, Medicare and Medicaid benefits and senior care industryLicense/Certification/RegistrationMinnesota Board of Nursing RN license in good standingPreferredEducationBachelor’s degree or higher in nursingExperienceThree to five years of experience in geriatric nursing, public health or care coordination/case management.Strong knowledge of managed care programs, long-term services and supports, Medicare and Medicaid benefits and senior care industryLicense/Certification/RegistrationMinnesota Board of Nursing Public Health Nurse licenseCertification in case management, gerontological nursing, or public health nursingOther Skills We Desire:Knowledge of third party payers, billing procedures and insurance.Ability to work independently and exercise independent judgment.Excellent customer service, public relations and communication skillsAbility to prioritize and work with a fluctuation in workload while working independentlyAbility to adapt to change and engage in ongoing process improvementFlexibility to work at other sites is encouragedWe are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, sex, gender, gender expression, sexual orientation, age, marital status, veteran status, or disability status. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation.EEO StatementEEO/AA Employer/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status