*This position is funded by the Boston Public Health Commission (Ryan White Part C Grant)*
The RN Case Manager will work providers and team nurses to assure that the patients referred for Nursing Case management receive patient assessment, care planning, education, follow up and support in developing and achieving their health related self management goals; and best health outcomes. The RNCM collects, maintains, reports and follows up on related medical data. She/he assists in the development of day-to-day management and long term planning for the patient’s care. The RNCM collaborates with health center providers and multidisciplinary professionals in providing for physical, psychological and/or social support for assigned patients and families. She/he identifies and establishes relationships with community resources which can contribute to the network of care for patients. The RNCM meets the requirements of the designated funding source in achieving required program goals.
The RNCM may participate in community outreach efforts as appropriate and as assigned. This may include serving as a health consultant for the Lynn Public Schools, local day care centers, after school program, day camps or other community related organizations; providing such services as programmatic consultation, preparation/review of health related policies and documentation or participating in health screenings, health education programs or counseling at health fairs and other similar community events.
- Respect and maintain patient confidentiality in all aspects of care including use of electronic information.
- Treat all patients in a welcoming and professional manner.
- Demonstrate professionalism by appropriate attire, attendance, attitude, and behavior within the clinical setting.
- Contribute to the team effort by supporting all team members and maintaining an open and positive attitude.
- Welcome new employees to the team by assisting with their orientation to the team and mentoring them, as requested.
DUTIES AND RESPONSIBILITIES:
- Establish contact with patients appropriate for RN Case Management due to diagnosis, treatment regime, risk status, compliance, recent ER usage or Grant specified target group criteria.
- In collaboration with the PCP, Team RNs, Clinical Pharmacist, other Providers, patient and family formulate a plan of care that supports best practice and guides the patient in achieving identified/revising Self Management goals. This plan may include medication management, diet counseling, exercise, referral for specialty care, education for proper use of medical equipment or supplies, update of immunizations, group or individual education and support.
- Coordinate with other departments and agencies to best meet patient needs (i.e. Enrollment, Social Services, WIC, HAWC, BH, SBHC, Dental, Eye, Pharmacy etc.)
- Assure that patients are scheduled for follow up, lab or other pertinent visits and receive periodic phone calls to support their health maintenance activities. Provide for follow up of no shows.
- Consistently use the learning assessment, appropriate teaching guidelines, plan of care, EHR/EPM to review and document patient interventions.
- Develop and utilize patient case registry and data collection programs to track, record and summarize patient information for funding sources.
- Participate in all applicable departmental, health center, and funding source meetings, educational programs, in-service training and/or conference calls to maintain professional and technical knowledge.
- Participate in the development and evaluation of applicable protocols, procedures and decision support tools.
- Collaborate and provide support to the team nurses, providers and staff regarding Case Managed Patient issues.
- Obtain required specimens and perform or request diagnostic tests. Ensure that provider and patient are notified of abnormal results.
- Perform functions as a Team RN or other related duties as required or assigned.
- Triage patient phone calls and identify need for urgent care, making appropriate patient care decisions.
- Maintain accurate patient records by recording nursing observations and interventions appropriately and within scope of practice.
- Perform or assign tasks associated with maintaining a properly stocked, safe and clean clinical environment.
- Participate in the development of team goals, objectives, protocols and procedures.
SPECIFIC DUTIES AND RESPONSIBILITIES:
- Provide comprehensive care to clients with human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and co-morbidities that are common with chronic infectious disease.
- Educate patients regarding risk reduction.
- Demonstrate knowledge of HIV transmission, disease process and treatment in all aspects of patient care.
- Include education on disease process, risk reduction, and medication adherence as a component of patient Treatment Goals.
- Record and submit information re: HIV and AIDS reportable cases for the MDPH AIDS surveillance program.
- Serve as the LCHC infectious disease nurse, in accordance with Lchc’S Post Occupational BBP Exposure Policy
- Facilitate Hepatitis B and Hepatitis C screening, treatment and follow up.
- Maintain professional and technical knowledge by attending HIV/AIDS trainings and other related continuing education units or language courses.
- Preview patient EHR and collaborate with provider to order or make referrals for those needed health maintenance tests/exams/procedures and/or vaccines, which are indicated for patients with HIV/AIDS.
- Demonstrates an understanding of customer service principles by successfully completing on-line Customer Service training.
- Utilizes the principles of customer service when interacting with patients/clients, team members and staff from other departments.
- Appropriately handles or seeks support when customer service breakdowns occur.
- Demonstrates knowledge of culture by successfully completing the on-line training on Cultural Competence.
- Utilizes an appreciation of and respect for diversity when interacting with patients/clients, team members and staff from other departments.
- Responds appropriately or seeks support when confronted with cultural biases or conflicts.
- Is aware that to respond promptly and appropriately to emergency situations, any staff member may be assigned to duties which differ from those in the job description or may be assigned temporarily to a different location.
- Understands that all staff should have a Personal Emergency Plan in place to best respond to his/her job responsibilities should a health center emergency arise.
- Graduate of an accredited nursing program.
- RN with current Mass. Licensure
- Previous experience in Community Health or Nurse Case Management preferred
- Bilingual in Spanish/Khmer/Russian beneficial
- History of good attendance and positive work attitude
- The essential duties of this position present risk of exposure to airborne infection, body fluids, and blood-borne pathogen. Annual BBP Training is required.
- Up to date immunization and annual TB testing is required. Hepatitis B vaccine and annual flu immunization are strongly recommended. All necessary vaccines are available at no charge at the health center. A Declination form must be signed if the Hepatitis B or other recommended vaccines are declined.
- Results of inquiry to Criminal Offender Record Investigation (CORI) must be acceptable under health center standards.
Lynn Community Health Center (LCHC) provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, LCHC complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, and transfer, leaves of absence, compensation and training. LCHC expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of LCHC’s employees to perform their job duties may result in discipline up to and including discharge.
Job Posting Id #18-089 (Part time 20 hours)