Pay Range: Commensurate based on education and experience

Benefits Eligible: True

Work Schedule: Monday – Friday, 8:00 a.m. to 5:00 p.m.

Travel: Not required

For Best Consideration Date: 

Position Introduction:

The OU Sooner Health Access Network (HAN), housed within the Department of Medical Informatics, is dedicated to advancing access to affordable, high-quality, person-centered care across Oklahoma. Partnering with primary care practices statewide, OU Sooner HAN delivers comprehensive support through innovative care management, quality improvement consulting, and targeted education and training. Our interdisciplinary team of RN and LCSW care managers provides tailored, one-on-one support for individuals with complex medical and social needs. By working closely with SoonerCare Choice and Aetna Better Health of Oklahoma members, we empower patients through informed decision-making and collaborative care planning. Services include in-depth health and social needs assessments, coaching for self-management, and connections to vital community resources. Care is delivered through flexible, patient-centered approaches including home and clinic visits, hospital coordination, telephonic outreach, and telehealth, ensuring accessibility and continuity at every step. As an NCQA-accredited program, OU Sooner HAN Care Management is grounded in evidence-based practices and a commitment to improving outcomes through comprehensive, coordinated care.

• Collaborate with members to create a member’s plan of care, including identifying goals, barriers and strengths.
• Clinical assessment of member’s medical and behavioral health, and social determinants of health.
• Assess barriers to achieving goals including health status, functional abilities, behavioral health, social issues, environmental and safety concerns, caregiver stability, self-management skills, and life care planning.
• Assess member’s strengths and confidence in achieving goals.
• Conduct ongoing medication reconciliations including assessing for barriers.
• Monitor and evaluate plans including progress toward goals, health status, medication reconciliation and member experience.
• Review and interpret medical test results.
• Evaluate effectiveness of medical treatments.
• Recognize and communicate signs and symptoms of change in member’s health status.
• Depending on the care management pathway followed, contact is provided daily to at least monthly to members:
  • home visits to evaluate home environments and family relationships, and to provide support and self-management coaching.
  • medical and pycho-social appointments to facilitate collaboration
  • telephone calls.
  • hospital visits.
  • secure email.
• Understands and is able to apply the concepts of disease management and risk management in service planning.
• Utilize critical thinking to assess alternative approaches to problems and/or decisions.
• Review and interpret therapist reports and psychiatry reports.
• Recognize and communicate with team any signs and symptoms of changing mental health needs.
• Crisis management.
• Link member and caregiver to supportive community services as needed and follow up to confirm contact.
• Facilitate access, communication and collaboration between member and all providers.
• Provide and coordinate transition services across all settings of care.

• Communicate care plan to all providers in all settings of care (Emergency Department, hospital, rehabilitation facility, home care, nursing home and specialists).
• Ensure member, caregivers and providers receive timely information for treatment decisions across all settings.
• Coordinate/verify services, equipment and supplies are in place.
• Reconcile medications at every contact.
• Regularly maintain records to document and monitor the care management activities in the management information system.
• Participate in regular interdisciplinary case staffing meetings and reviews.
• Communicate and collaborate with other providers (e.g., specialists, respiratory therapists, nutritionists, physical therapists, home health providers, care managers, social workers, etc.) by optimizing the office-based care team to send, receive, and triage information flows among the providers.

• Communicate with, educate and advise members and family, helping them to understand conditions and treatments.
• Participate in Quality Improvement activities.
• Monitor identified performance measures and deliverables and provide regular progress reports - Report submission will be determined as performance measures and deliverables are identified.
• Follow and practice defined evidence-based protocols in all care management related activities and responsibilities.
• Conduct assessments and monitoring within prescribed timelines.
• Other duties as assigned.

Values:

• Demonstrate and apply principles of person-centered, strength-based philosophy, motivational interviewing, shared decision making, coaching and adult learning
• Demonstrate a sensitivity and responsiveness to a variety of cultural values and beliefs and social determinants of health
• Practice trauma informed approach

Community Representative:

• Serve as an OU representative on community boards and task forces

View the full job description. 

Required Education and Experience:

• Bachelor's Degree in Nursing.
• 12 months of professional nursing experience.

Equivalent/ Substitution: Will accept an Associate's degree in Nursing and 24 months of professional nursing experience in lieu of the Bachelor's Degree for a total of 36 months professional nursing experience. 

Required Certifications and Licenses:

• State of Oklahoma Registered Nurse Certification.  

Hiring Contingent Upon a Background Check: Yes