POSITION SUMMARY:
This position is responsible for managing high-risk clients living in a residential substance use treatment center to promote effective education, self-management support and timely healthcare delivery to achieve optimal quality and financial outcomes. Responsibilities include providing and coordinating direct client care to improve quality of care through the efficient use of resources, enhancing quality, cost-effective outcome. Acts as an advocate for the individual’s healthcare needs, and coordinates care to minimize the fragmentation of health care delivery systems. This position is committed to the constant pursuit of excellence in improving the health status of the Y-Haven community.
ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Manages a careload of the residents with the most complex medical and psychiatric conditions (assist them with medication management, routinely test vital signs, blood sugar levels, oxygen levels, etc.) and maintain communication with their adjunct providers).
• Manages medication rooms and ensures compliance with CARF, Ohio MHAS, VA, and Ohio Medicaid standards.
• Facilitates specialized group counseling designed to provide education to support chronic disease management, smoking cessation, and psychoeducation.Provides basic medical education to the rest of the Y-Haven team once per month.
• Collaborates with providers and practice staff in identifying appropriate clients for care management, utilizing established Care Management criteria.
• Performs initial and periodic assessments for care-managed population. This includes physical and psychological assessments as appropriate. The assessment includes a systematic and pertinent collection of data about the health status of the client. Prioritize clients according to intensity, need and required follow up.
• Formulates and implements a care management plan that addresses the clients identified healthcare needs by assessing the client/family needs, issues, resources and care goals; determining the choices available to individual clients; educating the client/family on the choices available.
• Establishes a care management plan that is mutually agreed upon by the health care team and the client/family. Plans will contain specific mutual self-management goals, objectives, and interventions with the clients are action-oriented.
• Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues and goals. If certified in Advanced Practice with prescriptive authority, may make medication adjustments as needed in collaboration with Primary Care Provider. Monitors and evaluates the progress of the client.
• Collaborates with the SUD Treatment team, primary care provider organizations and community mental healthcare providers to revise the care management plan when changes occur. Initiates care conferences to discuss multidisciplinary team responsibilities, client progress, new problems, etc.
• Identifies and effectively utilizes community resources to meet the needs of clients/families. Facilitates client access to community medical resources as appropriate.
• Promotes client self-management and empowers clients/families to achieve maximum levels of wellness and independence. Interacts professionally with client/family and involves client/family in the formation of plan of care.
• Performs follow up calls for clients recently discharged from acute hospitalizations and who are considered high risk for readmission.
• Maintains EMR databases on care managed population. Maintains accurate and timely documentation in the EMR
• Reviews utilization and quality reports routinely and scans for gaps in care to identify clients needing the additional support of care management.
• Performs all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with basic principles and guidelines of professional nursing.
• Performs medication reconciliation for all care transitions.
• Participates in regular team meetings and peer review activities. Participates in quality and organizational committees.
• Participates in the orientation of new personnel. Precepts and mentors peers. Promotes collaborative teamwork.
• Abides by the organizations compliance program and requirements. Provides coverage across the organization as needed.
• Works collaboratively with leadership team to improve and enhance care delivery through the evaluation, development and enhancement of policy and procedures.

QUALIFICATIONS:
Education Requirements: The following education requirements are considered essential:

• RN required.
• Licensed to practice nursing in the State of Ohio
• Proficiency in medication indications and side effects.
• Understanding of medical tests and requirements for test as to provide the patients with appropriate information.

Experience and Skill Requirements: The following experience and skills are considered essential:

• Minimum of 3 year of professional level medical experience; experience in care coordination preferred.
• Experience working with an electronic medical records required.
• Ability to work collaboratively with people of diverse cultures and lifestyles. Ability to communicate effectively with providers and medical staff.
• Excellent organizational skills and ability to handle multiple priorities while remaining calm and professional.
• Ability to be self-motivating and work independently. Computer skills proficient to expert Excellent written and oral communication skills. Problem solving skills.