Patient Centered Health Home (PCHH) Nurse Case Manager

Job Description

Job Description

POSITION SUMMARY : Perform the duties required to coordinate and monitor provision of wellness and prevention initiatives for patients enrolled in Primary Health Homes.

POSITION QUALIFICATION REQUIREMENTS

Education : Registered Nurse or Bachelor of Science in Nursing.

Experience : Three (3) years as an RN in community clinic, public health nursing, and / or hospital setting; including dispensing sample drugs and monitoring effects.

Skills and Abilities (which may be representative but not all inclusive of those commonly, associated with this position) :

• Good computer skills including the use of word processing and e-mail software.
• Good oral and verbal communication skills.
• Good organizational and self-motivation skills.
• Ability to maintain confidentiality.
• Ability to motivate and educate clients and staff.

Transportation Requirement : Must possess a valid driver's license and automobile with insurance coverage as required by the State of Missouri.

License(s) / Certificate(s) : Licensed as RN in the State of Missouri; CPR certification.

FUNCTIONS OF THE JOB

Essential Functions

• Enrollment and management of required caseload. Completing monthly touches per regulations / guidance.
• Assist in developing treatment plan health care goals for individuals with co-occurring chronic diseases.
• Develop wellness and prevention initiatives.
• Facilitate health education groups.
• Keep patients' records. Complete appropriate forms and reports. Provide appropriate documentation. Adhere to patient confidentiality.
• Participate in the initial treatment plan development for all Primary care health home enrollees.
• Assist in contacting medical providers and hospitals for admission / discharge.
• Provide training on medical diseases, treatments, and medications.
• Initiate the referral of high-risk patients and families for special services, team management, and track the patient's referral (i.

e.) abnormal lab results.

• Collaborate with behavioral health and medical teams to develop patient-centered plan of care.
• Track required assessments and screenings.
• Assist with referrals to community and social support services.
• Assist in implementing MHD health technology programs and initiatives (i.e., Cyber Access, metabolic screening).
• Monitor HIT tools and reports for treatment.
• Medical alerts and hospital admissions / discharges.
• Monitor and report performance measures and outcomes.
• Consult with Community Support Staff regarding identified health conditions.
• Perform other duties as assigned.

Marginal Functions :

• Assist providers with enrolled patients, take and record vital signs, abnormal results, distribute sample medications and administer injections per provider's orders.
• Observe signs and symptoms, document, and report reactions of the treatment to the provider.
• May perform home visits as needed.
• Assist with implementation of Quality Improvement Programs.

Supervises : None

NOTE : Affinia Healthcare is a Covid-19 Vaccine Mandated Employer. All employees of Affinia Healthcare are required to be vaccinated for Covid-19.

NOTE : SMOKING IS PROHIBITED IN THE WORK ENVIRONMENT

NOTE : ALL APPLICANTS MUST PROVIDE CONTACT INFORMATION FOR THREE REFERENCES

AN EQUAL OPPORTUNITY SERVICES PROVIDED ON A NON-DISCRIMINATORY BASIS