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Nurse Care Coordinator

Job Code:12741

Department:Behavioral Health Home

FT/PT Status:Full Time

Summary:

The Nurse Care Coordinator shall provide regional primary care consultation, psychiatric care consultation; work with the Behavioral Health Home Organization (BHHO) & Certified Community Behavioral Health Clinic (CCBHC) team, Child Assertive Community Treatment Team, Private Non-Medical Institute, and other members to facilitate care across the healthcare continuum.

$10,000 sign-on Bonus!

Pay starts at $33/hour!

ESSENTIAL FUNCTIONS:

+ Provide education and support around medications to the Interdisciplinary Team (IDT), members, and families.

+ Provide medical education about chronic disease management to IDT members, families and groups.

+ Liaison to Health Home, ACT Teams, CCBHC Practices/Primary Care Physicians.

+ Collaborate with the IDT on member plan of care.

+ Review Health Questionnaire and provide recommendations to IDT and/or members and families for medically compromised participants.

+ Assist, and/or make recommendations regarding skill development in activities of daily living, including hygiene, nutrition, exercise, general health maintenance/improvement.

+ Support implementation of grant funded projects such as In-Shape, CTI, and other health and wellness pay for performance initiatives in geographical area where program is offered.

+ Support Behavioral Health Home team, CCBHC and Child ACT in achieving organizational and state required outcomes, including but not limited to A1C testing, tobacco screening and annual health screenings.

+ Be proficient in EHR, HIN, and VMS systems in order to extract clinical data and alerts in order to support level of care.

+ Consult with IDT and members as indicated regarding discharge planning recommendations and follow up.

+ Monitor emergency department usage and coordinate with IDT and other providers to promote least restrictive level of care.

+ Medication reconciliation through EHR from external providers (i.e. PCP, Specialists, etc.) when appropriate.

+ Provide medication and medical education to Interdisciplinary Team (IDT), members, and families.

+ Complete pharmacy enrollments, medical equipment orders, and other supports/services to support recovery goals.

+ Provide CRMA Training and Supervision as needed.

+ Schedules will vary according to program needs (as applicable):

+ On-call responsibilities as assigned

GENERAL EXPECTATIONS:

+ Provide excellent customer service

+ Active participation in supervision of student interns, as appropriate and needed.

+ Ensure the confidentiality of all patient information and release of information from area(s) of responsibility.

+ Ability to support and recognize the important role volunteers play. Sweetser employees work with, support, collaborate with volunteers, and promote opportunities for volunteer engagement

+ Exercise judgment consistent with clinically accepted standards of community practice in determining whether to transport a particular patient(s).

+ Maintain adequate personal vehicle insurance coverage, a valid state driver’s license, a vehicle that is in good repair and a good driving record as per organization policy.

+ Active participation in required supervision as determined with Program Manager according to licensure level.

+ Timely and accurate provision of administrative paperwork according to the time frame established by the organization’s policies.

+ Active participation in administrative meetings, including program meetings and general staff meetings.

+ Understand and comply with all Sweetser policies and procedures as identified in the Human Resources Policy Manual.

+ Maintain administrative responsibility (charting/documentation, etc.)

+ Active participation in in-service training and continuing education programs.

+ Active participation in providing community education to staff, community groups, etc., as appropriate and needed.

+ Maintain minimum number of training hours mandated by professional licensure and required by state licensing.

+ Maintain relationships with patients that promote dignity, equality and self-determination.

+ Provide productive and supportive collaboration with peers/colleagues in the same program and across programs.

+ Maintain productive and efficient relationships with all organization-wide personnel and programs.

+ Maintain positive representation of the organization, at all times, with the public.

+ Follow Suicide safer care practices.

+ Other duties as assigned.

EDUCATION:

+ Graduate from an accredited school of nursing.

CERTIFICATES, LICENSES, REGISTRATIONS:

+ Current RN license in the State of Maine.

+ Maintain a valid state driver’s license.

+ Must be able to speak, read, and write English fluently.

EXPERIENCE:

+ Previous experience working with adults with serious and persistent mental illness preferred.