Nurse Case Manager

Job Title: Registered Nurse

Job Status: Full-time

Job Summary: Under limited supervision, uses intermediate skills obtained through experience and training to improve the physical health status of clients with serious mental illness, including those with co-occurring substance use disorders, who have or are at risk for comorbid primary care conditions and chronic disease. Conduct assessments, draft client care plans, make changes to treatments in care plans. Manages transitions of care with hospital discharge planners. Coordinates care of all clients still in Treat-to-Target stage or high disease acuities. Supervises a team of care workers and wellness coaches and utilizes an Electronic Health Record system to ensure that there is no break in the care provided.

Essential Duties and Responsibilities:

• Conduct social and medical risk assessments on clients including monitoring patient vital signs and develop plans of care specific to their health needs. Assessments may be conducted on ACCESS property or in clients homes
• Enroll clients into appropriate program benefits and activities and monitor progress. Coordinate the delivery of benefits and services to clients. Refer clients to other services as needed
• Advocate on behalf of client in written and oral form when providing necessary referrals and contacts with other departments/agencies/companies
• Assist clients in recognizing and understanding “at risk” behaviors.
• Provide one to one health education to clients
• Plan, provide and/or conduct educational presentations to clients
• Functions as a member of a multidisciplinary team that includes a nurse practitioner and clinicians
• Review, interpret and explain to program participants the policies and procedures of the program
• Document all services in compliance with the agencies quality assurance plan. Report on program progress at required intervals per funding guidelines
• Develop and update educational materials for use by patients. Participates in team reviews, staff meetings and staff trainings
• Maintain agency confidentiality, client’s privacy, and HIPAA compliance
• Supervise, coach, and assess staff performance
• May participate in grant proposal writing and submission
• May participate in audits as needed

• Maintains currency on new developments in the nursing field as mandated by the National Council of State Boards of Nursing

• Operates standard office equipment and uses required software applications.
• Shall follow the funding sources requirements and CARF standards applicable to the services you provide
• Performs other duties and responsibilities as assigned

Knowledge, Skills, and Abilities:

Knowledge of:

• Guidelines and standards of the program
• Medical/ health and social risk standards
• Fundamental knowledge of concepts, practices and procedures used in nursing education and counseling as well as public health and dealing with high risk populations
• Intermediate math skills
• Basic knowledge of training design and culturally sensitive delivery for individuals and groups

Skill in:

• Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems
• Instructing — Teaching others how to do something
• Operating standard office equipments and using required software applications, including Microsoft Office, Excel and PowerPoint, the reporting software recommended by funding agency and the ACCESS Electronic Health Record system

Ability to:

• Actively listen to clients
• Partner with other functional areas to accomplish objectives

• Facilitate meetings, ensuring that all viewpoints, ideas, and problems are addressed.
• Organize and prioritize multiple tasks and meet deadlines
• Communicate effectively, both orally and in writing

• Speak and write in English. Ability to interpret, speak and write in Arabic, Spanish or other native language of the predominant service population a plus
• Maintain confidentiality of agency and client information
• Work independently as well as collaboratively within a team environment
• Handle stressful situations and provide a high level of customer service in a calm and professional manner
• Establish and maintain effective working relationships

Educational/Previous Experience Requirements:

• Minimum Degree Required:

• Associate’s Degree in Nursing
  • • Bachelor’s Degree in Nursing preferred

~and~

• • • Minimum of two years experience in supervising a team in a community health setting or other related health field or any equivalent combination of experience, education, and/or training approved by Human Resources.

Licenses/Certifications:

• Licenses/Certifications Required at Date of Hire:
  • Must be registered nurse in good standing based on current licensure requirements administered by the Michigan Board of Nursing Department of Licensing and Regulatory Affairs.

Working Conditions:

Hours: Normal business hours. Some additional hours may be required.

Travel Required: Local travel may be required.

Travel required within Wayne, Oakland, and Macomb Counties. Travel throughout the state may be required based on the assigned functional area.

Working Environment: Climate controlled office environment during normal business hours.