Nurse Care Manager Health Home - RNs/NPs/PAs $55,759-$72,487

Description

Job Summary and Scope

As a member of the Medical Services Team’s   Health Home program, provides care coordination for clients with substance   use disorder (SUD), Severe and Persistent Mental Illness, Intellectual Disabilities,   and complex chronical medical conditions, in the office and community setting,   under minimal supervision. All Health Home team members are responsible for providing outreach   and client engagement services, after care and discharge planning, and care   coordination for clients enrolled in the program(s). The health home Nurse serves in an expanded role to collaborate with members   of the client’s care team including: PCP (Primary Care Provider),   specialists, pharmacy, other community agencies and other services providers within   CWN (Centra Wellness Network), and patients/families to ensure the delivery   of quality services specific to client need. Assesses plan, implements,   coordinates, monitors, and evaluates all options and services with the goal   of optimizing treatment needs and client’s health status. Integrates   evidence-based clinical guidelines, preventive guidelines, and protocols, in   the development of individualized care plans that are patient-centric, use of   evidence-based practices in treatment of SUD and behavioral health issues   along with promoting quality and efficiency in the delivery of health care.   The employee will complete other tasks as needed in various programs as   assigned by the supervisor.

CWN   recognizes all person’s vulnerabilities to trauma, and traumatic experiences   and that impact on daily living. It is our practice to use practice models   suitable to our job that are evidence based or sound practices that support   our daily functions, models of treatment, and strength-based initiatives and   outcomes. As a member of the CWN team staff will provide support throughout   the agency, develop leadership skills, complete their tasks with efficiency   and effectiveness and accept that all practices adhere to a recovery-based   practice, providing the supports and guidance to empower, and promote   recovery in clients and peers. CWN strives for collaborative relationships   within the community, working with others in a professional, respectful, and   positive manner that enhances a culture of creativity and support.

Position Specific – Duties and Responsibilities

Job Specific: All   staff have specific job duties required to be successful in this job, and   they will practice within the license and scope of practice. 

· Staff must possess   computer, typing, grammar, and phone proficiencies; and have excellent   communication and public relations skills to effectively interact with   customers, other providers, and community stakeholders. 

· The employee must have   an appropriate level of independent decision-making and problem-solving; and   work effectively in a team-based environment. 

· Coordinates care across   settings and helps client/families understand all treatment interventions and   available health care options. 

· Manages a caseload of   complex patients. Provides targeted interventions to support office-based   outpatient treatment (OBOT) for opioid addiction, stabilize behavioral health   issues and avoid hospitalization and emergency room visits. 

· Identifies the targeted high-risk population within   practice site(s) SUD diagnosis, per PCP referral, risk stratification, and   clients lists. 

· Provides assessment including SUD, behavioral health   issues and any impact they have on health care issues. 

· Provide ongoing assessment over time regarding health   care, educational, and psychosocial needs of the client/family.  Uses standardized assessment tools such as   depression screening, functionality, and health risk assessment.

· Collaborates with Health Home team, PCP, clients, and other members of the med   services and/or health care team.

· Participates in the   PCP/IPOS process, and documents comprehensive goals in the individualized   plan of service and targeted interventions. Continually monitors client/family   response to plan of care and revises the care plan as indicated.

· Provides client   self-management support with a focus on empowering the client/family to build   capacity for self- care.

· Implements systems of   care that facilitate close monitoring of high-risk clients to prevent and/or   intervene early during acute exacerbations. Monitors mental and physical health   status, including monitoring medication reconciliation.

· Coordinates client care   through ongoing collaboration with PCP, patient/family, community, and other   members of the OHH/BHH care team. Fosters a team approach and includes client/family as active members   of the team. Takes the lead in ensuring the continuity of care and serves as   liaison to acute care hospitals, specialists, and post-acute care   services. 

· Provides follow-up with client/family when client   transitions from one setting to another. Completes timely post-hospital follow-up: Medication reconciliation, PCP or   specialist follow-up appointment, assess symptoms, teach warning signs,   review discharge instructions, coordination of care, and problem solve   barriers, etc. 

· Demonstrates excellent written, verbal, and listening   communication skills, positive relationship building skills, and critical   analysis skills. 

· Builds and maintains effective relationships with   community partners and promotes an integrated approach to health and wellness   and recovery.

· Completes screenings and assessments for assuring   medical necessity and determining the appropriate level of care up to and   including voluntary and involuntary psychiatric hospitalization.

· Provides timely clinical documentation in the electronic   medical record that includes amount, scope and duration of services provided   in accordance with the person-centered plan. Complies with agency policy,   DCH, CARF, and Medicaid criteria for clinical documentation for all aspects   of the medical record including, but not limited to, intake assessments,   person-centered plans, plan reviews, releases of information,   progress/activity notes, annual psycho-social assessments and discharge   summaries.

· Promotes recovery and empowers clients in their ability   to make positive life choices while promoting good mental and physical   health. Oversees the development,   training and distribution of prevention and wellness information and   initiatives. 

· Completes all tasks and assignments assigned by the Med   Services Supervisor. 

· Meets as needed with Hospital Diversion team for   consultation and resource development under guidance of the supervisor.

· May participate in coverage of crisis services specific   to the Health Home as needed. 

· Works with leadership and others to continuously   evaluate process, identify problems, and propose/develop process improvement   strategies to enhance care management. 

· Reviews the current literature regarding effective   engagement and communication strategies, care management strategies, best   practice models of treatment and behavior change strategies and incorporates   into clinical practice. 

· Promotes recovery and respects the   choices and autonomy of clients, while teaching and encouraging actions that   will promote recovery.

· Participates in   team meetings and other staff meetings as requested, and meets regularly with   supervisor for consultation, supervision, and resource development.

· Prepares for and facilitates health   Home Huddle meetings with other providers to assure communication and   consistency in treatment by all members of the client’s treatment team.

· Maintains and compiles information   and data to produce and report on program outcomes.

· Complies with all policies and procedures of the agency.

Organizational Wide-Duties and   Responsibilities:

· Customer Services: Treats   customers and co-workers with dignity and respect. Presents a professional   image to consumers in appearance and work habits and works within boundaries   of CWN ethical standard in the Compliance Plan, and regarding standards   associated with position responsibilities. Maintains confidentiality in   accordance with CWN policies and procedures and HIPPA guidelines. 

· Teamwork: Works   collectively to enhance team performance. Promotes discussions that share   knowledge and experiences and promotes positive team solutions regarding team   conflicts and performance issues. Assists co-workers to contribute to overall   success of the team and agency. 

· Problem Solving and   Decision Making:  Independently   identifies and solves problems with an appropriate level of supervisory   direction. Applies sound problem-solving skills. Decisions reflect the best   interest of the organization. Accepting responsibility for decisions and   resulting consequences. 

· Communication:  Communicates   (oral and written) professionally, respectfully, and positively with clients,   coworkers, community members.  

· Productivity and   Quality: Meet expectations   set by agency relative to productivity (volume of work, accuracy, and   timeliness of its completion) and quality as defined by the position.  

· Computer Systems:    All employees must possess a sufficient understanding of computer operation   to be able to navigate in and out of software to effectively learn and   utilize the Agency’s electronics systems and various software programs. All computer systems   access and electronic activities must  

· Integrity:   Demonstrates responsible and honest behavior in all   roles, tasks and responsibilities. Follows through on commitments. Follows   agency policies and procedures.

· Confidentiality:   Observes all rules of confidentiality, both internally specified by poly and   procedure and externally required by law.

· Reliability:   Personally responsible; completes work in a timely, consistent manner; works   hours necessary to complete assigned work; is regularly present and punctual;   arrives prepared for work; is committed to doing the best jo possible; keeps   commitments 

· Mandatory Trainings   and Self Development: Understands training   requirements and attends required curriculum. 

· Guidance/Work   Direction Received: Follows   established policies, procedures, or practices in performing most duties and   assignments.

To perform this job successfully, an individual must be   able to perform each essential duty satisfactorily. The requirements listed   below are representative of the knowledge, skill, and/or ability required.   Reasonable accommodations may be made to enable individuals with disabilities   to perform the essential functions.    

Requirements

Qualifications, Skills, and Conditions

Knowledge,   Education and Training (licenses, programs, or certificates): 

· Must have current Michigan Registered   Nurse, Licensed Practical Nurse, Nurse Practitioner, or Physician Assistant   license.

· LPNs must meet the   following requirements:

- Minimum of one year   experience in a managed care setting preferred and a minimum of three to five   years medical nursing, surgical nursing and/or nursing in the acute care   setting. Practice within scope of licensure.

· Knowledge of chronic physical and   mental conditions and substance use disorder, evidence-based guidelines,   prevention, wellness, health risk assessment, and patient education required.   

· Training and education in Substance   Use Disorders, Behavioral Health, and Co-occurring disorders.

· Training and/or knowledge of the   impact of SUD and mental illness on physical health. 

· Experience in motivational   interviewing and skills for client engagement along with other interventions,   screenings and treatments used in behavioral health and substance use   disorders, including understanding of Stages of Change by Sharon Melnick, MD. 

· Knowledge of Excel spreadsheet and   other standard office software.

Interpersonal and   Communication Skills: Regularly interpreting and   translating facts and information; explaining situations and issues to people   and advising them of alternative or appropriate courses of action; and/or interviewing   and developing information from others on an unusual or difficult level. Experience in care management and/or   continuous quality improvement preferred. Must demonstrate a high level of skill in problem-solving, crisis   management and customer services. Ability to quickly formulate steps for intervention when crisis   issues, complaints or disagreements occur. 

Guidance/Work   Direction Received: Follows established policies,   procedures or practices in performing most duties and assignments, but   discretion is frequently required in selecting appropriate courses of action.

Supervisory or   Managerial Responsibility: No managerial or supervisory authority.

Visual   Concentration: Requires an average level of visual   concentration.

Job Complexity:   Regularly requires planning, solving problems, analyzing situations, making   decisions, or thinking creatively.

Job Impact:   

· Impacts measures of financial   activity or results on a regular basis, but to a moderate degree. Impact would not be viewed as causing   significant financial harm to the Agency or as providing significant   opportunities for enhancing the financial position of the Agency. 

· Errors in judgment may have a   significant impact upon the well-being or legal rights of others.

Working Conditions: 

· No unusual physical exertion is   required.

· Some pressure to meet deadlines with   job tasks, assignments and project may occur occasionally. 

· Work is regularly carried out in   mildly disagreeable conditions. Factors such as temperature, noise, or other surroundings yield an   identifiable level of discomfort.

· Tasks performed produce exposure to   injuries such as minor burns, cuts, abrasions, or falls beyond that of the   typical office environment regularly.

· Requires travel to all CWN sites, to   meetings and client homes in Manistee and Benzie Counties, with occasional   travel out of the county for other job-related assignments, trainings or   presentations. 

Specific   Requirements:

· Must have a valid Michigan’s driver’s   license and a good driving record.

· Must be available to work a fully   flexible schedule including evenings, weekends and holidays.

· Must be certified in First Aid and   CPR within 90 days of hire.

· Required to sustain State Licensure   in field of practice and/or Certifications in order to perform duties of the   job

Salary : $55,759 - $72,487