Job Description
Compensation : $ or $ hourly
Due to critical service need of the communities we serve, we are offering a $6000 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!
This is a Full-time, benefit eligible position. The schedule is Monday - Friday 8 : 00am-4 : 30pm.
The Nurse Care Manager is part of the person-centered integrated care team and provides individual and population-based health interventions to persons enrolled in the Health Care Home by integrating care for physical health conditions into the behavioral health setting.
ESSENTIAL FUNCTIONS JOB SPECIFIC
- Responsible for completion of monthly assigned interventions, and all aspects of care according to DMH regulations, for a case load of up to 200 Healthcare Home clients
- Meet with assigned clients to complete health screening initially and annually; identify risk level, care caps and make recommendations
- Assist in developing a physical health goal for the Wellness Plan; promote healthy lifestyles including healthy nutrition, physical activity, and freedom from tobacco / nicotine use
- Ensure that clients are referred to a PCP and / or Specialist if they do not have one; provide education to clients regarding the importance of having a PCP and encourage regular usage of their PCP for screening and management of chronic health conditions;
provide education regarding the appropriate use of PCP / Urgent Care / ED
- Complete Metabolic Syndrome Screenings on assigned clients following the Metabolic Screening Policy and Standing Order
- Perform Medication Reconciliations for HCH enrollees who have been discharged from the hospital per agency guidelines
- Provide education to clients / caregivers identified on monthly reports, and as needed, regarding physical health conditions, treatment, screening, prevention, and self-management
- Provide consultation and education for community-based and office-based staff about identifiable health conditions
- Consult with Specialized Healthcare Consultant as scheduled and as needed
- Assist in contacting / collaborating with medical providers and other human / social service agencies regarding significant health information to ensure the provision of holistic services
- Function as part of a multi-disciplinary team; attend team meetings, CPRC / SUD team huddles, and integrated meetings as assigned
- Attend agency meetings and DBH / Council meetings as assigned
- Travel to assigned clinics; travel to other clinics / locations for nursing coverage and trainings / meetings as needed
- Travel to client’s home when indicated
- 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 agency consumer and family member
- Other duties as assigned
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