Job Description

About CINQCARE

CINQCARE is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to Black and Brown communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our Family Members’ race, culture, and environment is critical to delivering improved health outcomes. By empowering Family Members, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care.

About You

The RN should have the following qualifications:

• Education: Active GA state Registered Nursing license. BSN required.
• Experience: At least 5 years of relevant clinical experience. Ideal candidates will have 3+ years of relevant care management experience in the health plan, home health and or hospice.
• Entrepreneurial: CINQCARE seeks to fix gaps that have persisted for generations in the delivery of care to Black and Brown populations. This position is accountable for ensuring CINQCARE is positioned to innovatively deliver on its promise. The RN Advocate will possess the ability to work independently and initiate change within their responsibilities.
• Communication: Excellent verbal, written communication and presentation skills; ability to clearly articulate and present concepts and models in an accessible manner.
• Relationships: Ability to build and effectively manage relationships with patients, the community business leaders, and external constituents.
• Culture: Good judgement, impeccable ethics, and a strong team player; desire to succeed and grow in a fast-paced, demanding, and entrepreneurial Company.

About the Job

The RN Case Manager reports to the Director of Clinical Operations, with accountability for providing strategy, judgement, organization, and evidence-based analysis to influence decisions and directly meet CINQCARE requirements. The candidate should embody CINQCARE’s core values, including, Trusted, Empathetic, Committed, Humble, Creative and Community-Minded.

The RN will have the following responsibilities:

• The individual in this position works as part of an interdisciplinary team to ensure high quality outcomes for CINQCARE’s members/families struggling with chronic disease management.
• Develops Alert-driven care pathway templates by condition with risk levels and member actions by event type.
• Uses Care Pathway templates by Chronic Condition with Alerts to develop Member Action Plans.
• Deploys Remote Patient Monitoring and Patient Self Reporting for High-Risk Chronic Conditions.
• Conducts in-home or tele-health assessments, when necessary.
• Responds real-time to members alerts and is in active communication with the member and caregiver via text and phone. Monitors remote patient monitoring tools and notify interdisciplinary team when follow-up is required to address out of range results and or clinical outcomes.
• Provide care coordination for CINQCARE’s members including patient navigation, chronic disease management/education and interdisciplinary collaboration while complying with department policies and procedures and other contractual requirements.
• Work with patient and care team to conduct assessments that result in a Member Action Plan prioritized by the patient and care givers. Track Member Action Plan outcomes, interventions, and continue to reassess the patient's needs as appropriate. Establish appropriate timeframe for frequency of follow-up activities and provide closure and referral services as patients move through the care continuum.
• Engage patients in taking a proactive role for managing their health, medications, treatment and mental health needs, and follow-up appointments and refer patients to the appropriate community-based organizations or other programs.
• Follow evidence-based guidelines and contact standards to facilitate closure of gaps in care and encourage and use of in network services and determine when in-home services are needed and ordered.
• Use the electronic medical record or Care Management platform to conduct care coordination activities and comply with associated policies and procedures including those for workflow and consistent documentation.
• Participate in team-based rounds to support and contribute to ongoing program design and development as lessons are learned from the field and process improvement work performed within in the department.
• Reassesses Member Action Plan Post Discharge.
• Demonstrates an ability to identify and shift priorities within work assignment to effectively manage patient care load.
• Collaborates daily with interdisciplinary team for assigned patients to discuss patient care planning and care facilitation.
• And of course, perform other job-related duties as assigned.

The RN will also have the following duties:

• Leadership : The RN Advocate will lead in defining and executing strategies and solutions to create business value in the clinical practice, including working with their team to design, develop, and execute those strategies and solutions to deliver desired outcomes.
• Strategy : The RN Advocate will establish the business strategy and roadmap: (1) improve outcomes for CINQCARE members; (2) enhance the efficacy of other CINQCARE. business divisions; and (3) develop and deliver external market opportunities for CINQCARE products and services. In establishing the business strategy, the RN Advocate will define and innovate sustainable revenue models to drive profitability of the Company.
• Collaboration : The RN Advocate will ensure that our clinical capabilities form a cohesive offering, including by working closely with other business divisions to learn their needs, internalize their knowledge, and define solutions to achieve the business objectives of CINQCARE.
• Knowledge : The RN Advocate will provide subject matter expertise in the clinical solutions, including determining and recommended approaches for highest quality medical care, including assessment and event-based care management
• Culture : The RN Advocate is accountable for creating a productive, collaborative, safe and inclusive work environment for the clinical team and as part of the larger Company.

The working environment and physical requirements of the job for the RN Advocate include:

This position requires both in-home and office-based work. The job requires frequent travel for home visits and travel to physician offices, hospitals, sub-acute facilities, community partners and non-home-based market offices in all types of weather conditions. In-office work is performed indoors in a traditional office setting with conditioned air, artificial light, and an open work space.

In this position you will need an ability to travel frequently by car and/or public transportation, the ability to communicate with customers, vendors, management, and other co-workers in person and over devices, sometimes with people who are agitated. Regular use of the telephone and e-mail for communication is essential. Sitting for extended periods is common. Must be able to receive ordinary information and to prepare or inspect documents. Lifting of up to 30 lbs. occasionally may be required. Good manual dexterity for the use of common office equipment such as computer terminals, calculator, copiers, and FAX machines. Good reasoning ability is important. Able to understand and utilize management reports, memos, and other documents to conduct business.

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