Mobile Nurse Care Manager

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 Homeless and Residential Programs and the Hub of Hope. All locations serve adults who are homeless, may be seeking recovery from dependence to substances, and who may also have a co-occurring mental illness.

**Not eligible for HRSA Loan Repayment**

Essential Duties and Responsibilities

Care Management

• For those residents requiring and agreeable to nurse care management services: coordinates with residential program staff, 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.
• Educating the patient and/or support system in areas such as recovery from substance dependence, disease-specific management, medication management, healthier life-style choices, stress reduction, chronic disease management, and pharmacological agents.
• Facilitate individual or group sessions which provide education to staff and residents on health-related topics and activities that enhance recovery and self-care management.
• 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).
• Participates in regular residential/outreach meetings for case review and discussion of evidence-based chronic disease management, integrated care best practices

Direct Clinical Care

• 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. Duties include, but are not limited to:
• Vital signs including ability to interpret pulse oximetry
• Perform AIMS assessments
• Medication injections & immunizations
• Venipuncture
• First aid
• Review monthly Residential medication room audits in accordance with PH med monitoring policy.
• Provide staff training and education to ensure proficiency with medication monitoring, as well as other topics critical to management of the target population.
• Wound care
• Facilitate vision screenings and assist patients with obtaining corrective eyewear.
• Explore options for other on-site healthcare services including podiatry and vaccinations in collaboration with the Philadelphia Department of Health.
• In collaboration with Hub of Hope Medical Team, Residential staff, and hospital providers, assess for and facilitate admissions to Serenity Court Homeless Medical Respite.
• Counsel patients and assess readiness to change regarding recovery, health care and lifestyle choices.
• Assess and manage patients’ needs related to acute and/or chronic health conditions.
• Facilitate scheduling of appointments & procedures such as colonoscopies, biopsies, radiology studies, chemotherapy, lab testing, medical/dental/psychiatric evaluations and other health-related activities.
• Obtain prior authorization for medications, procedures, or other services as needed.
• Provide guidance to Residential staff regarding symptom assessment of residents with acute and chronic health conditions.
• Assess the need for durable medical equipment and collaborate with PCP, medical home, insurer, pharmacy, and/or medical supply company to obtain necessary items.
• improvement.
• Participate in Project HOME/PHHS Quality Improvement initiatives.
• Attend all mandatory Project HOME/PHHS mandatory trainings and/or trainings recommended by Direct Supervisor(s).
• Maintain nursing licensure and CPR certification.

Documentation

• Inputs all required care management data into EHR.
• Per HIPAA regulations, obtain all necessary signed written authorizations from residents to coordinate and share information with other healthcare providers, including PHHS, and Residential case managers.
• Ensure that residents sign an annual Privacy Notice.
• Maintains own training, certification, and continuing education activity log for reference at mid-year and annual performance reviews.

Minimum Qualifications

• Bachelor of Science in Nursing (BSN)
• Active RN license in Pennsylvania
• BLS certification

Preferred qualifications

• Three years of relevant work experience

Project HOME is an Equal Opportunity Employer. All offers of employment are contingent on successful completion of a drug screen and background checks.

Project HOME reserves the right to revise or change job duties and responsibilities as needed. This job description is not meant to be an all-inclusive statement of the duties and responsibilities of the job nor does it constitute a written or implied contract.