AMH+ RN Care Manager

Job description

Job Description: The RNCM manages a panel of rising and high intensity members to support integrated chronic disease and behavioral health care for the members. The RNCM collaborates with members to create a care plan and oversees progress to the plan, frequently reassessing needs, coordinating with providers and specialized resources, and partnering closely with the Community Health Partner to build trust and demonstrate advocacy. Responsibilities: Receive members from the engagement and care team, clearly communicating program expectations, including duration and goals. Complete self-efficacy and condition-specific screeners during the assessment and intake phase, along with behavioral health screeners like PHQ-9, GAD-7, AUDIT, and DAST-10 to identify behavioral health needs. Conduct in-person clinical examinations when appropriate and collaborate with care team members to determine member placement in programs of varying intensity. Prepare for and actively participate in case conferences, leading discussions when necessary. Develop a care plan in collaboration with the member and address social needs with the support of the Community Health Partner. Conduct regular clinical visi...