Patient Centered Health Home (PCHH) Nurse Case Manager

About the Role

Coordinate and monitor the provision of wellness and prevention initiatives for patients enrolled in Primary Health Homes.

Qualifications

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.

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

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

Skills and Abilities

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

Responsibilities

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

Marginal Functions

• Assist providers with enrolled patients, take and record vital signs, abnormal results, distribute sample medications, and administer injections per provider's orders.
• Observe signs and symptoms, document, and report reactions of the treatment to the provider.
• May perform home visits as needed.
• Assist with implementation of Quality Improvement Programs.

Smoking is prohibited in the work environment.