Job Summary: The Registered Nurse (RN) Care Manager provides a holistic, trauma informed and patient-centered approach in caring for patients seen through Project HOME's Healthcare Services. Principle roles include:
Serves as a key member of an PHHS team and instrumental to its success.
Works 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.
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 EHR.
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.
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
Education and Experience Minimum Requirements:
Minimum Experience
Bachelor of Science in Nursing (BSN)
3 years of prior experience as a nurse care manager
Active RN license in Pennsylvania
BLS certification
Preferred Experience
One or more years' experience working as an RN with the target population
Physical Requirements
Minimal lifting, 10 pounds or less
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.