Minimum Starting Salary: $77,136
Job Summary:

The Nurse Care Manager2(NCM-2) provides a holistic, trauma informed and patient-centered approach in caring for patients seen through Project HOME's Healthcare Services Mobile Medical Team and the HUB of HOPE. Principle roles include: working closely with participants, other Project HOME (PH) stakeholders, Project HOME Healthcare Services(PHHS), and other primary care providers to provide coordinated intake assessments, goal-setting, and plans of care for patients seen by the mobile medical team and at the HUB of HOPE; collaborating with street outreach teams to coordinate care delivery for patients who are unhoused or marginally housed; assessing, triaging and responding to patients with acute, chronic, and preventive health and wellness needs; providing medical services in various settings including but not limited to clinics, private/group residences, and on the streets of Philadelphia: and providing mentorship for PHHS nurse care managers who are new to the role.

Essential Duties and Responsibilities

Care Management

• Coordinate with primary care providers, behavioral health providers, and other providers in implementing individual care plans, especially follow-up plans from ER or hospital discharges.
• Conduct information-sharing, goal setting with the participant, pre-visit planning and after-visit follow-up, exploring gaps in care and working to eliminate them.

• Educate 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.
• Conduct street-based/mobile health visits with participants whose mental/physical/emotional conditions may prevent them from accessing care in a formal clinic setting.
• Provide care coordination and injection management support for patients receiving long acting injectable medications.

Direct Clinical Care

• Demonstrate clinical excellence, flexibility, patience, critical thinking/decision-making, and ability to teach and collaborate with providers and patients.
• Perform clinical assessments and procedures including venipuncture and immunizations using universal precautions, aseptic technique as required, and in accordance with proper OSHA standards.
• Perform AIMS assessments
• Perform wound care
• Counsel patients and assess readiness to change regarding recovery, healthcare and lifestyle choices.
• Obtain prior authorization for medications, procedures, or other services as needed.
• Assess the need for durable medical equipment and collaborate with PCP, medical home, insurer, pharmacy, and/or medical supply company to obtain necessary items.
• Participate in Project HOME/PHHS Quality Improvement initiatives.
• Provides mentorship for PHHS nurse care managers who are new to the role
• 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.

• Bachelor of Science in Nursing(BSN)
• 3 or more years of prior experience as a nurse care manager
• Active RN license in Pennsylvania
• BLS certificationWhat Experience and Background you Bring to the Role:

• Experience as a RN with people who use opioids, and knowledge of Medication Assisted Treatment is beneficial.
• Background in trauma informed care, person centered recovery, and harm reduction models or similar experience is a plus.
• Ability to establish and strengthen relationships with the community, medical partners and Project HOME staff across the organization.

Requires long periods of standing and ability to carry supplies needed for caring for patients at street side.

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.