The Nurse Case Manager will provide clinical nursing support for Opioid Use Disorder Program and for the Integrated Primary Care Teams. The Nurse Case Manager will provide skilled nursing care, assessment, care planning, care management and coordination of the plan of care for a specified population of patients in need of intensive care management. Nurse Case Manager will provide care coordination, transitional care from inpatient to other settings, and referral to community and social support services. Nurse Case Manager will also participate in shared treatment planning and health promotion activities.
- 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.
SPECIFIC DUTIES AND RESPONSIBILITIES:
- Works in collaboration with the consumer, the behavioral health therapist and the primary care provider to provide care management, care coordination, and/or health promotion as needed to accomplish the shared treatment plan.
- Identify consumers needing follow-up care management, care coordination, and/or health promotion services using the EHR-based population care management registry.
- Assess consumers and recommend PBHCI Health Promotion programs.
- Initiates appropriate referrals to additional services including home care and notifies appropriate support staff of referrals to ensure authorization.
- Coordinates medical/health care appointments.
- Works with the PCP, inpatient providers, discharge planners and nurse partners to ensure efficient use of inpatient resources and a timely discharge to an appropriate setting. Makes onsite visits as indicated.
- Documents the level of understanding and response to teaching.
- Participates in quality improvement activities as required.
- Travel to meetings, conferences and trainings may be required.
ADDITIONAL DUTIES AND RESPONSIBILITIES:
- Provide Substance Use Disorder nurse case management for multiple integrated primary care teams on a dedicated schedule.
- Completion of grant-related paperwork and data entry into database.
- Participate in risk rounds to assess high risk patients.
- Co-facilitate group therapy with Behavioral Health staff and/or Recovery Coaches within the integrated primary care teams.
- Responsible for administering induction of MAT, discussing side effects, and monitoring for adverse reaction.
- Complete follow-up appointments for providers due to missed appointments or provider absence.
- Collaborate with detox facilities, hospitals, and jails to coordinate care as needed/required.
- Provide overdose and Narcan training to patients and family members.
- 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.
- Must be graduate of accredited nursing porgram
- Current Massachusetts Registered Nurse license
- Must have minimum of 2 years clinical experience in acute care/medical surgical settings
- Significant experience in home care and/or community settings, and discharge planning and case management experience desired.
- Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion
- Bilingual preferred.
- 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: 21-197, 21-201