Patient Centered Health Home (PCHH) Nurse Care Manager

POSITION SUMMARY: Perform the duties required to coordinate and monitor provision of wellness and prevention initiatives for patients enrolled in Primary Health Homes.

POSITION QUALIFICATION REQUIREMENTS

Education: Registered Nurse Diploma or Bachelor of Science in Nursing.

Experience: Three (3) years as an RN in community clinic, public health nursing, and/or hospital setting; including dispensing sample drugs and monitoring effects.

Skills and Abilities (which may be representative but not all inclusive of those commonly, associated with this position):

1. Good computer skills including the use of word processing and e-mail software.
2. Good oral and verbal communication skills.
3. Good organizational and self-motivation skills.
4. Ability to maintain confidentiality.
5. Ability to motivate and educate clients and staff.

Transportation Requirement: Must possess a valid driver's license and automobile with insurance coverage as required by the State of Missouri.

License(s)/Certificate(s): Licensed as RN in the State of Missouri; CPR certification.

FUNCTIONS OF THE JOB

Essential Functions

1. Enrollment and management of required caseload. Completing monthly touches per regulations/guidance.
2. Assist in developing treatment plan health care goals for individuals with co-occurring chronic diseases.
3. Develop wellness and prevention initiatives.
4. Facilitate health education groups.
5. Keep patients' records. Complete appropriate forms and reports. Provide appropriate documentation. Adhere to patient confidentiality.
6. Participate in the initial treatment plan development for all Primary care health home enrollees.
7. Assist in contacting medical providers and hospitals for admission/discharge.
8. Provide training on medical diseases, treatments, and medications.
9. Initiate the referral of high-risk patients and families for special services, team management, and track the patient's referral (i.e.) abnormal lab results.
10. Collaborate with behavioral health and medical teams to develop patient-centered plan of care.
11. Track required assessments and screenings.
12. Assist with referrals to community and social support services.
13. Assist in implementing MHD health technology programs and initiatives (i.e., Cyber Access, metabolic screening).
14. Monitor HIT tools and reports for treatment.
15. Medical alerts and hospital admissions/discharges.
16. Monitor and report performance measures and outcomes.
17. Consult with Community Support Staff regarding identified health conditions.
18. Perform other duties as assigned.

Marginal Functions:

1. Assist providers with enrolled patients, take and record vital signs as necessary, review and report abnormal results.
2. Observe for abnormal signs and symptoms, document, and report to provider.
3. Assist with implementation of Quality Improvement Programs.
4. Attend mandatory meetings and training courses.
5. Submission of monthly reports as scheduled.

Supervises: None

NOTE: SMOKING IS PROHIBITED IN THE WORK ENVIRONMENT

NOTE: ALL APPLICANTS MUST PROVIDE CONTACT INFORMATION FOR THREE REFERENCES

AN EQUAL OPPORTUNITY SERVICES PROVIDED ON A NON-DISCRIMINATORY BASIS