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.
Care Management:
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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.
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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.
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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.
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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).
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Participates in regular interagency, interdisciplinary care meetings for case review and discussion of evidence-based chronic disease management, integrated care best practices
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Conduct occasional mobile health visits with participants whose mental/physical/emotional conditions may prevent them from accessing care in a formal clinic setting.
- Serves as a key member of an PHHS care team and instrumental to its success.
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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.
- Works closely with the nursing team and MOUD care team to facilitate effective coordination and communication of participant plans of care.
- Assess, triage, and respond to patients with acute, chronic, and preventive health and wellness needs.
Direct Clinical Care:
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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.
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
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Bachelor of Science in Nursing (BSN)
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Active RN license in Pennsylvania
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BLS certification
Preferred Experience
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One or more years' experience working as an RN with the target population
Physical Requirements
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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.