Job Summary: The Nurse Care Manager is a key member of an integrated health care team and instrumental to its success. The primary focus for this position is providing care management to targeted patients at the Stephen Klein Wellness Center.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Care Management

o For those participants requiring and agreeable to nurse care management services: coordinates with primary care providers, behavioral health providers, and other providers in implementing individual care plans, especially follow-up plans from ER or hospital discharges.

o Information-sharing, goal setting with the participant, pre-visit planning and after-visit follow-up, exploring gaps in care and working to eliminate them.

o Educating participants and/or support system in areas such as harm reduction and/or recovery from substance dependence, disease-specific management, medication management, healthier life-style choices, stress reduction, chronic disease management, and pharmacological agents.

o Facilitate individual or group sessions which provide education to staff and participants on health-related topics and activities that enhance recovery and self-care management.

o Coordinating care with intensive emphasis during critical care transition points (e.g., from hospital/ED to home, from street to housing, from specialist to primary care, from primary care to hospice).

o Conduct occasional mobile health visits with participants whose mental/physical/emotional conditions may prevent them from accessing care in a formal clinic setting.

Direct Clinical Care

o Performs clinical assessments and procedures using universal precautions, aseptic technique as required, and in accordance with proper OSHA standards. 

Duties include, but are not limited to: 

o Provide staff training and education to ensure proficiency with medication monitoring, as well as other topics critical to management of the target population. 

o Utilize harm reduction model and person-centered care delivery. Counsel patients and assess readiness to change regarding recovery, health care and lifestyle choices. 

o Collaborate with Program Manager and other key stakeholders to identify areas for improvement. 

o Participate in Project HOME/PHHS Quality Improvement initiatives. 

Documentation 

o Inputs all required care management data into EHR. 

o Maintains own training, certification, and continuing education activity log for reference at mid-year and annual performance reviews. 

The information contained herein is not intended to be an all-inclusive list of the duties and responsibilities of the job. Management may, at its sole discretion, assign or reassign duties and responsibilities to this job at any time. 

Project HOME offers a competitive compensation package which includes health, prescription, dental, and vision coverage at minimum cost to our employees, company funded life and disability insurances, paid parental leave, spending accounts, and 401K plan with 100% matching contributions up to 5% of compensation. Additionally, we offer generous PTO accruals which includes paid sabbatical leave.

EDUCATION AND EXPERIENCE 

MINIMUM REQUIREMENTS: 

Minimum Experience: 

· Bachelor of Science in Nursing (BSN) 

· Current RN license 

· CPR certification 

· EHR 

Preferred Experience: 

· One or more years' experience working as a RN with the target population. 

Core Skills: 

· Strong interpersonal skills 

· A combination of life and work experiences and education that demonstrates the ability to collaborate effectively with people of different backgrounds, abilities, opinions, and perceptions to achieve significant organizational change. 

PHYSICAL REQUIREMENTS: SEDENTARY WORK THAT PRIMARILY INVOLVES SITTING/ STANDING. 

Project HOME provides equal employment opportunities to all employees and applicants for employment, without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability status, protected veteran status, genetic information, or any other characteristic protected by federal, state, or local laws. Project HOME prohibits discrimination and harassment of any type.