Job description
Location: East Hollywood, Vermont.
Classification: Full Time
Position Purpose:
The RN Case Manger coordinates with all parties involved in the medical care of the patient (interdisciplinary team, patient, family, and significant others) to provide the most effective care and treatment for those who are high utilizers of services, individuals and families experiencing homelessness, adults with serious mental illness or substance use disorders and adults and children transitioning from incarceration. This position is also shared with our MCC-HIV program serving people living with HIV/AIDS. This position develops effective care plans based upon assessment data and provision of care priorities, in collaboration with the Clinical Social Worker. The RN Case Manager coordinates patient care and collaborates with other health care team members to establish the patients' goals, develop treatment plans, and obtain desired outcomes. The RN Case Manager modifies plans of care based on reassessment findings and specific patient care needs. The RN Case Manager recognizes change in patient status and takes timely and appropriate interventions; provides patient education based on identified learning needs utilizing available teaching resources; communicates identified needs to members of the interdisciplinary team.
Principal Responsibilities:
Preferred:
The RN Case Manger coordinates with all parties involved in the medical care of the patient (interdisciplinary team, patient, family, and significant others) to provide the most effective care and treatment for those who are high utilizers of services, individuals and families experiencing homelessness, adults with serious mental illness or substance use disorders and adults and children transitioning from incarceration. This position is also shared with our MCC-HIV program serving people living with HIV/AIDS. This position develops effective care plans based upon assessment data and provision of care priorities, in collaboration with the Clinical Social Worker. The RN Case Manager coordinates patient care and collaborates with other health care team members to establish the patients' goals, develop treatment plans, and obtain desired outcomes. The RN Case Manager modifies plans of care based on reassessment findings and specific patient care needs. The RN Case Manager recognizes change in patient status and takes timely and appropriate interventions; provides patient education based on identified learning needs utilizing available teaching resources; communicates identified needs to members of the interdisciplinary team.
Principal Responsibilities:
- Collaborates with Providers, Managed Care Plans, Housing Navigation Team, and community-based service providers to provide enhanced care coordination for eligible patients and/or entities to ensure a seamless experience for the patient and non-duplication of services.
- Provide targeted HIV and chronic disease Case Management (CM) Services to low-income populations.
- Conducts case management services to include intake and assessment, develop comprehensive care plan, implementation of care plan, subspecialty referrals, monitoring and follow-up.
- Case conferences with medical provider, as appropriate and by acuity.
- Continuously documents client interventions, progress in achieving medical goals.
- Collects, reports and manages aggregate and individual client data using CaseWatch and NextGen EMR.
- Collaborates with multi-disciplinary team, including, but not limited to medical, behavioral health, and other health services.
- Participates in case conference/clinical supervision sessions with multi-disciplinary team
- Maintains documentation of all client contacts and assists in preparing timely reports
- Participates in Staff Meetings and trainings
- Maintains contract and HIPAA compliance as indicated by DHSP guidelines.
- Provides clients with referrals as appropriate.
- Conducts follow up assessments with clients per clinical assessment and referrals.
- Performs quality improvement activities per contract/agency policy (i.e., patient satisfaction surveys);
- Connect Member to other social services/support services and provide appropriate referrals for subspecialty care (i.e. ophthalmology, behavioral health, podiatry, nutrition, health education, etc.), transportation, food, housing, etc. Accompany Member to office visits, as needed.
- Advocate on behalf of Members with health care professionals
- Use motivational interviewing, trauma- informed care, and harm-reduction approaches
- Coordinate with hospital staff on discharge plan
- Monitor treatment adherence (including medication)
- Provide health promotion and self- management training
- Participates in agency and community meetings pertaining to the needs of patients and issues related to Case Management diseases.
- Other duties as assigned.
Requirements:
1. Licensed in good standing in the State of California as a Registered Nurse.
2. RN licensure and three (3) years of HIV clinical practice experience and relevant experience within the scope of their licensure (based on the standards of the discipline).
3. Current HIV/AIDS and STI’s knowledge and trained in HIV counseling.
4. Effective oral and written communication skills.
5. Working knowledge of word processing (MS Word) and spreadsheet (MS Excel) programs.
6. Experience with electronic health records system.
Preferred:
- Bilingual (English/Spanish).
- Case-Watch experience.
- Knowledge and experience using behavior change model.
- Knowledge and experience using risk reduction counseling.
Desirable Qualifications/Skills:
- Highly organized and able to maintain client files, charts and test results.
- Ability to work in a multi-disciplinary team setting.
- Ability to empathize with patients and build rapport.
- Trained in co-morbidities: HIV, STDs, Hepatitis and Tuberculosis transmission and treatment.
- Experience in the disclosure of life altering conditions.
- Ability to talk openly about sex and sexual risk behaviors, as well as substance use risk reduction.
- Knowledge of HIV disease, including natural history, symptoms, and current treatment.
- Demonstrate a history working with the target population, inclusive of cultural competency and sensitivity, including that of persons living with HIV.
- Knowledge and experience working with behavioral risk groups, including Injection Drug Users, Youth and the Lesbian Gay Bisexual and Transgendered Community.
- Knowledge of substance abuse issues and treatment, and related sexual risks.
- Good interpersonal skills and ability to work well with other members of the clinical and case management team.
- Motivate clients to modify HIV risk taking behaviors and substance use behaviors.
- Experience coordinating medical and psychosocial services for clients.
All JWCH, Wesley Health Centers workforce members must be fully vaccinated against COVID-19 as a condition of employment. Successful candidates for this position will be required to submit proof of vaccination against COVID-19 or request an exemption for qualifying medical or religious reasons during the onboarding process. Candidates should not present proof of vaccination until instructed to do so by the hiring department.
Employee Benefits :
JWCH Institute, Inc., offers competitive salaries for all positions. Employees working 30 hours per week or more are provided a monthly allowance which can be used towards medical, dental, vision, and life insurance premiums. The agency offers sick leave and vacation accrual, 11 paid holidays, jury duty pay, mileage reimbursement, employee parking, direct deposit, credit union, and an employee assistance program. In addition JWCH offers a 401(k) Profit Sharing plan to employees who work a minimum of 1,000 hours per fiscal yea
Wesley Health Centers, JWCH Institute is an Equal Opportunity Employer.
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