Job Summary:
The Mobile Registered Nurse Care Manager (NCM) Demonstrates clinical excellence, flexibility, patience, critical thinking/decision-making, and ability to teach and collaborate with providers and residents. Performs clinical assessments and procedures in accordance with proper OSHA standards. Collaborates with Program Managers, Residents, and Internal/External Stakeholders to coordinate intake assessments, set goals, and develop plans of care. Utilizing a holistic, trauma informed, and patient-centered approach, the NCM provides medical/nursing consultation and support, as well as care to residents living at Project HOME residential sites. This position is currently based four days at the Sacred Heart Recovery Residence and one day at the St. Elizabeth's Recovery Residence. This is a rewarding opportunity for an experienced nurse to build relationships and provide quality care to those with a history of homelessness, co-occurring mental illness, and or seeking recovery from dependence to substances.
Principle responsibilities include:
Serves as a key member of a Project HOME Healthcare Services (PHHS) team and instrumental to its success.
Collaborates 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.
Assess, triage, and respond to patients with acute, chronic, and preventive health and wellness needs.
Provides mentorship for PHHS nurse care managers who are new to the role.
Essential Duties and Responsibilities:
Care Management
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.
Information-sharing, goal setting with the participant, pre-visit planning and after-visit follow-up, exploring gaps in care and working to eliminate them.
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.
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.
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).
Participates in regular interagency, interdisciplinary care meetings for case review and discussion of evidence-based chronic disease management, integrated care best practices
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:
Demonstrates clinical excellence, flexibility, patience, critical thinking/decision-making, and ability to teach and collaborate with providers and patients. 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:
Vital signs including ability to interpret pulse oximetry
Perform AIMS assessments
Medication injections & immunizations
Venipuncture
First aid
Provide staff training and education to ensure proficiency with medication monitoring, as well as other topics critical to management of the target population.
Wound care
Facilitate vision screenings and assist patients with obtaining corrective eyewear.
Explore options for other on-site healthcare services including podiatry and vaccinations in collaboration with the Philadelphia Department of Health.
Utilize harm reduction model and person-centered care delivery. Counsel patients and assess readiness to change regarding recovery, health care and lifestyle choices.
Assess and manage patients' needs related to acute and/or chronic health conditions.
Facilitate scheduling of appointments & procedures such as colonoscopies, biopsies, radiology studies, chemotherapy, lab testing, medical/dental/psychiatric evaluations and other health-related activities.
Obtain prior authorization for medications, procedures, or other services as needed.
Provide guidance to case management staff regarding symptom assessment of residents with acute and chronic health conditions.
Assess the need for durable medical equipment and collaborate with PCP, medical home, insurer, pharmacy, and/or medical supply company to obtain necessary items.
Collaborate with Program Manager and other key stakeholders to identify areas for improvement.
Participate in Project HOME/PHHS Quality Improvement initiatives.
Attend all mandatory Project HOME/PHHS mandatory trainings and/or trainings recommended by Direct Supervisor(s).
Maintain nursing licensure and CPR certification.
Provides mentorship for PHHS nurse care managers who are new to the role
Assisting in running PHHS COVID vaccination clinics
Documentation:
Inputs all required care management data into Next Gen and Social work software.
Per HIPAA regulations, obtain all necessary signed written authorizations from residents to coordinate and share information with other healthcare providers, including PHHS, and Residential case managers.
Ensure that participants sign an annual Privacy Notice.
Maintains own training, certification, and continuing education activity log for reference at mid-year and annual performance reviews.
Education and Experience Minimum Requirements:
Minimum Qualifications:
Bachelor of Science in Nursing (BSN)
3 years of prior experience as a nurse care manager
Active RN license in Pennsylvania
BLS certification
Awareness and willingness to travel between and into residential locations in North Philadelphia
Physical Requirements:
Minimal lifting, 10 pounds or less
Preferred Qualifications:
One or more years' experience working as an RN with the target population
Experience as a visiting/mobile/traveling nurse
Benefits
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.
At Project HOME we are committed to equal employment opportunity and advancement regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity or gender expression or Veteran status. All offers of employment are contingent on successful completion of a drug screen and background checks.