Nurse Care Manager (PT)

FLSA STATUS: Non-Exempt
STATUS: Part-Time
REPORTS TO: DD (Developmental Disabilities) Health Home Director

PRIMARY PURPOSE OF JOB

The Abilities First DD Health Home Nurse Care Manager (NCM) plays a pivotal role in managing the full array of healthcare needs adopting a whole-person approach that encompasses both physical and behavioral aspects for individuals served in the DD Health Home. The NCM will promote the provision of the six core services of the DD HH program including care management, care coordination, health promotion, comprehensive transitional care, individual and family support, and referral to community and social support services.  The NCM will work closely with the DD Health Home Director, Physician Consultant or APRN, and the Specialized Healthcare Consultant as well as other members of the individual’s health team.  The NCM will conduct health assessments, assist in developing and monitoring individual plan health goals and progress related to medical, behavioral, pharmaceutical, and social needs.  The NCM is responsible for overseeing the health trends of the entire population of individuals served and providing individual and population health education services.

ESSENTIAL FUNCTIONS AND KEY RESPONSIBILITIES

• Facilitate an organized, interdisciplinary team approach to care management.
• The NCM will meet with individuals assigned to the Abilities First DD HH to explain to the individual the benefits and purpose of the DD HH program.  The NCM will obtain the individual’s consent to remain in the DD HH program during the initial meeting.
• The NCM must conduct a chart review within 30 days of enrollment of the individual into the DD HH program.  In this process the NCM will become familiar with the clinical record and individual’s history and identify and prioritize health issues which may exist.
• The NCM shall complete a Metabolic Syndrome (MBS) screening with individuals within 30 days of DD HH enrollment and annually thereafter. The DD HH will coordinate with the individual’s PCP to determine the recommended time frame for obtaining new lab values.
• The NCM must document the reviews in individuals’ medical records; notes must, at a minimum, document the chart review occurred.
• As part of comprehensive care management services, the DD HH NCM is responsible for completing standardized, comprehensive assessments of individuals’ health needs. The health information will be documented on a Health Screen form.
• The DD HH NCM must have a face-to-face with the individual and parent/guardian to review the health information, discuss healthcare concerns, and help translate health and wellness goals for inclusion in the individual’s DD HH healthcare goals. Monitor and regularly follow up on patients' progress, adjusting treatment plans as necessary.
• As part of Care Coordination, health promotion and family support services, the NCM will help develop an overall person-centered plan for each individual that coordinates and integrates all clinical and non-clinical healthcare related needs and services and facilitates the individuals’ participation in the ongoing revision of their DD HH healthcare goals.
• The NCM will encourage active individual involvement through appropriate linkages, referrals, coordination, and follow up to needed services and supports.
• The NCM will document individual services in the individual’s medical record including but not limited to comprehensive care management monitoring for care management gaps.  Documentation must meet the DMH/MO HealthNet requirements.
• The NCM will utilize the DMH/DD identified system on a regular basis and are able to revise DD HH healthcare goals, as necessary.
• The NCM must perform medication reconciliation interventions and sign off on the medication reconciliation when complete. A progress note must be entered in the individual record documenting the completion and results of the medication reconciliation.  A transfer or hospital follow-up and medication reconciliation review must occur within 72 hours for any DD HH enrollee that has been discharged from the hospital.
• The NCM will develop educational groups to teach individuals how to manage their chronic illnesses and encourage healthy lifestyles.
• The NCM is responsible for overseeing the health trends of the entire population of individuals; following-up on identified trends impacting the health of the population; addressing high utilizers; participating in health education activities, including, as examples, topics on smoking cessation, disease prevention, and medication adherence.
• The NCM will coordinate care of DD HH participants enrolled in Managed Care Organizations (MCO) including keeping MCO apprised of individual’s needs; follow up with the individual’s interactions with the MCO during scheduled visits or phone calls; notify the MCO of individual’s discharge from the DD HH, as applicable.
• The NCM will maintain relationship and coordinate communication with individuals’ primary care physician.  Assist the enrollee in acquiring a primary care physician when needed.
• NCM may not exceed the maximum 1 FTE: 200 individuals served ratio. This includes staff filling these roles on a part-time basis.

EDUCATION, TRAINING AND EXPERIENCE REQUIREMENTS

• Registered Nurse who has a current Missouri or compact RN license recognized by the Missouri State Board of Nursing as an RN.

Or

• Licensed Practical Nurse who has a current Missouri or compact LPN license recognized by the Missouri State Board of Nursing as an LPN.
• Experience in the IDD field is preferred but not required.

KNOWLEDGE, SKILLS, AND ABILITIES

• Knowledge and experience teaching self-management.
• Excellent telephone and interpersonal communication skills.
• Ability to multi-task and prioritize, strong organizational skills.
• Strong knowledge of Medical Terminology.
• Computer experience required.

CORE COMPETENCIES

• Adaptability – Maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusting effectively to work within new work structures, processes, requirements, or cultures.
  Continuous Improvement – Originating action to improve existing conditions and processes, identifying improvements opportunities, generating ideas, and implementing solutions.
• Contributing to Team Success – Actively participating as a member of a team to move the team toward the completion of goals.
• Decision Making – Identifying and understanding issues, problems, and opportunities; comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action or developing appropriate solutions; taking action that is consistent with available facts, constraints, and probable consequences.
• Engagement Readiness – Demonstrating a willingness to commit to one’s work and to invest one’s time, talent, and best efforts in accomplishing organizational goals.
• Planning and Organizing – Establishing courses of action for self and others to ensure that work is completed effectively.
• Quality Orientation – Accomplishing tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
• Technical/Professional Knowledge and Skills – Having achieved a satisfactory level of technical and professional skill or knowledge in position-related area, keeping up with current developments and trends in area of expertise.
• Leadership Disposition – Demonstrating the traits, inclinations, and dispositions that characterize successful leaders; exhibiting behavior styles that meet the demands of the leader role.

PHYSICAL CONTEXT AND WORK ENVIRONMENT

Reasonable accommodations may be made to enable individuals with disabilities to perform essential job duties.

• The work environment is usually a well-lighted, environmentally controlled indoor environment with moderate level of noise.
• Works in an office environment with the option for some remote work
• Abilities First offers a flexible schedule and relaxed environment

The statements herein are intended to describe the general nature and level of work being performed but are not to be seen as a complete list of responsibilities, duties, and skills required of personnel so classified.

Also, they do not establish a contract for employment and are subject to change at the discretion of the employer.