Position Summary The goal of the Medical Case Manager (MCM) Nurse is to provide a wide range of client-centered services that ensure the provision of patient-centered, cost effective, high quality care. Patients under the care of the MCM Nurse will be supported by a multi-disciplinary team consisting of the patient, physician/nurse practitioner, and program staff to ensure timely and coordinated access to primary medical care, medications, and other support services, including treatment adherence to address the needs of patients requiring high risk patient care to include those living with HIV/AIDS. In the model for MCM Nurse, the role is provided by a registered nurse (RN) and will focus on the clinical services of primary care needs, to ensure that the patient enrolled in primary care receives associated services such as oral health, nutritional assessment, substance abuse and mental health interventions, treatment adherence support, prevention education, and partner notification. In addition, MCM services must include initial comprehensive assessment of the clients’ needs and personal support systems and to enroll clients in all relevant federal, state, and local entitlement programs to ensure compliance with program funding policies. The level of medical case management needed by the individual clients is determined by the initial intake assessment. To the extent necessary based on the acuity of needs, the MCM Nurse services includes coordination of inpatient and outpatient care, referrals to specialists, follow-up referrals and missed appointments, and regular care conferencing between clinical care providers, community-based care providers, and interdisciplinary care teams. Under the supervision of the Chief Medical Officer and the HIV Program Manager, and in collaboration with the Director of Nursing, the Clinic Administrative Staff, the incumbent serves to: Provide face-to-face nursing assessment and reassessment to include history taking and an appraisal of the patient’s health status and needs. Development of an individualized Nursing Plan to include:Providing relevant self-management support for patients with chronic illnesses as identified by clinical teams.Working with patients both in person and over the phone to remind and review their plan of care and progress towards their goals.Link patients with community resources to facilitate referrals and respond to social service needs:Utilize referral protocols and agreements with subspecialists to meet patients’ needs and achieve goals and objectives in their plan of care.Education and counseling about HIV transmission, disease management, risk reduction and harm reduction. Case management of medication therapy to include client education concerning risks and side effects, monitoring disease process to include lab values, monitoring client adherence and tolerance of medications. Identify patients within the team with anticipated high cost care, recent hospital admission requiring transition of care from hospital to home, high utilization of services, complex medical needs or those at high risk for complications or exacerbation from disease.Track and support patients when they obtain services outside the center such as the Emergency Department, hospitals and other subspecialists.Follow up with patients within a few days of an emergency room visit or hospital discharge.Track completion of laboratory tests, diagnostic studies and referrals as directed by providers and in collaboration with clinical team.In collaboration with administrative staff and enabling services, assist patients with the process of determining eligibility and to obtain and maintain free pharmaceuticals through the Patient Assistance Program. Be the system navigator and point of contact for patients and families, with patients and families having direct access for asking questions and raising concerns. Address patient and family concerns and initiate corrective action. Bring identified issues to the attention of supervisor. Assist patients in problem solving potential issues related to the health care system, financial or social barriers (e.g., request interpreters as appropriate, transportation services or prescription assistance). Triage patients who present to the health center and who require evaluation for routine, acute, emergent, or urgent care. Handle phone calls from patients seeking medical information and/or medical attention.Furnish medical advice per approved triage reference books. Process medication refill requests. Correctly assess stat triage patient’s vital signs and charts them accurately.Assist the office staff to appropriately identify the patient’s acute needs and direct that patient to receive the care required. Assist in transfers to hospital.Collect data and prepare reports and registries for review by the QA/PI Committee. Ensure timely documentation in Electronic Health Records, in the CAREWare database, and all other applicable databases.Participate in Performance Improvement/Continuous Quality Improvement activities. Adhere to policies/safety practices established by the Zufall Health Center. Maintain confidentiality of all patient information. Work effectively with other members of the health care team to optimize interventions. Work with the CMA and the other PCC to organize the clinical stock, check it in as it arrives, place it in the correct area whether in the clinical stock room, cabinets in the room or refrigerators. Work with CMAs to make sure stock is ordered in a timely manner to prevent lack of timely care for the patients. Perform other duties as assigned.Knowledge, Skills and Abilities Excellent customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.Excellent verbal and written communication skills. Bilingual in Spanish/English, preferred Ability to anticipate primary care providers needs. Excellent computer skills, experience with electronic medical records a plus Ability to interact with patients, staff and outside agencies appropriately. Ability to follow instructions, given either orally or in writing. Ability to work independently or with little supervision. Excellent organizational skills such as problem solving, decision making, priority setting, and work delegation. Ability to complete assignments in a timely manner. Ability to work as a team member. Ability to maintain HIPAA compliance, corporate compliance and client confidentiality.Education, Training and ExperienceRegistered Nurse and current license to practice as a Registered Nurse in the State of New Jersey. One to two years experience in a clinical setting, including direct patient care and triage experience. Prior experience in an ambulatory care or outpatient clinic setting and case management experience preferred. Possess thorough knowledge of practical nursing theory, standard practices, rules, and regulations related to nursing, knowledge of anatomy and physiology, and knowledge of aseptic technique.