Description:
POSITION PURPOSE
The Healthcare Home Nurse Care Manager is part of the person-centered integrated care team and provides direct clinical and medical services to persons enrolled in the Health Care Home through a whole person approach.
ESSENTIAL FUNCTIONS JOB SPECIFIC
Responsible for case load of up to 250 Healthcare Home patients
Meet with assigned clients to complete health screening
Assist in developing treatment plan healthcare goals for individuals with co-occurring chronic disease
Meet with assigned clients prior to monitor/educate on clients medical needs as needed
Provide consultation and education for community and office-based staff about identifiable health conditions
Assist in contacting/collaborating with medical providers regarding significant health information
Provide education to clients on medical diseases, treatment, and medication
Monitor HIT tools and reports for treatment and medication alerts and hospital admissions/discharges
Review monthly care manager reports, focusing on targeted population/indicators. The NCM will analyze the information and communicate/collaborate with providers, clinicians and clients
Coordinate Metabolic Syndrome Screenings and provide follow up for positive screens per DMH directive
Perform Medication Reconciliations for HCH enrollees who have been discharged from the hospital
Interface with other human/social service agencies to provide holistic services to clients
Function as part of a multi-disciplinary team
Will seek culturally competent services and service providers to meet the unique cultural needs of each agency consumer and family member
Travel to neighboring clinics for nursing coverage and training as needed
Report to Regional Primary Care Nursing Director for guidance and questions regarding clinical supervision issues
Other duties as assigned
ESSENTIAL FUNCTIONS COMPANY WIDE
Regularly attends work except for approved absences
Attends all training as required
Maintain professional, champion behavior
Provides quality customer service
Provides services with a commitment to service excellence
Works in a way that exhibits a commitment to personal excellence
Team oriented and values diversity
WORKING CONDITIONS & EXPOSURE RISK
Regular exposure to blood, body fluids, and biohazard waste materials
EDUCATION
High School/GED required
Practical Nursing or Registered Nursing degree required
Bachelors degree in nursing preferred
WORK EXPERIENCE
At least five (5) years of experience providing medical nursing services to individuals required for an LPN
At least two (2) years of experience providing medical nursing services to individuals preferred for an RN
Proficiency in Microsoft Office Suite and Electronic Medical Records preferred
LICENSURE/CERTIFICATION
Licensed Practical Nurse (LPN) required
Registered Nurse (RN) preferred
Compass Health is an Equal Opportunity/Affirmative Action Employer and an E-Verify participant.
Employment Type: Full-Time
