Due to critical service need of the communities we serve, we are offering a $8,000 sign-on bonus.* We are eager to continue to provide quality and compassionate care in our service areas and need you to make this happen!
The Nurse Care Manager in DD Healthcare Home is part of the person-centered integrated care team and provides individual and population-based health interventions to persons enrolled in the DD Health Care Home by integrating care for physical health conditions.
This is a Full-time, benefit eligible position working Monday - Friday. Travel will be required over various counties. These will be discussed further during the hiring process.
ESSENTIAL FUNCTIONS JOB SPECIFIC :
- Responsible for the completion of monthly assigned interventions, and all aspects of care according to Department of Mental Health regulations for the DD Health Home Program for a caseload of up to 200 clients
- Meet with assigned clients to complete health screening initially and annually in an office-based or community-based setting;
identify risk level, care gaps and make clinical care recommendations
- Assist in developing a physical health goal for the service plan; promote healthy lifestyle including healthy nutrition, physical activity, and freedom from tobacco use
- Ensure that clients are referred to a PCP or specialist, if they do not have one; provide education to clients / caregivers regarding the importance of having a PCP
- Complete metabolic syndrome screenings on assigned clients following the metabolic screening policy and standing order
- Perform medication reconciliation for assigned clients who have been discharged from the hospital per agency guidelines
- Provide education to clients and caregivers on monthly reports, and as needed, regarding physical health conditions, treatment, screening, prevention, and self-management
- Provide consultation and education for other care team members regarding chronic health conditions
- Consult with Specialized Healthcare Consultant and Primary Care Physician Consultant as scheduled and as needed
- Assist in contacting / collaborating with medical providers and other human service agencies regarding significant health information to ensure the provision of holistic services for assigned clients
- Travel to client’s place of residence as needed
- Meet service provision expectations per client needs and company guidelines
- Will seek culturally competent services and service providers to meet the unique cultural needs of each client
- Function as part of a multi-disciplinary team; attend team meetings, and other assigned community meetings
- Other duties as assigned
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