Description The Nurse Case/Program Manager position is contingent upon grant funds, employment will depend on the successful acquisition and continuation of the behavioral health grant. Salary: $83,000.00 / year This dual-role position is part of a Behavioral Health-Primary Care Integration Grant aimed at both enhancing healthcare delivery for patients with chronic behavioral health needs who face barriers to care and at improving capacity for the delivery of patient-centered integrated BH and primary care at all CHP sites. The Nurse Case/Program Manager will be part of a robust, collaborative team of medical and behavioral health providers and a CHW/peer recovery coach. This role dedicates 20 hours per week to administrative duties, including data collection, program management, and financial oversight, ensuring the grant's objectives are met. The remaining 20 hours focus on clinical care, providing direct patient support such as medication management, nurse visits for chronic conditions, and Medication-Assisted Treatment (MAT) for addiction. This role plays a pivotal part in bridging gaps in care, improving low threshold access to comprehensive integrated care, improving outcomes, and supporting CHP's goal to be a patient centered medical home with increased capacity for vulnerable patient populations. This person will support CHP's mission, vision, and values and will adhere to compliance protocols as well as CHP's policies and procedures. Position Requirements Nurse Case/Program ManagerEssential Duties and Responsibilities:
- Administrative Role
- Data:
- Acts as a liaison to the data management firm hired by the state to ensure the firm is getting the proper data on our new patients.
- Works collaboratively with team to ensure accurate and timely data collection.
- Ensures patient confidentiality, complying with all CHP, state, and federal privacy rules regarding patient data.
- Program management:
- Works with the Grant Director to oversee the grant's administration to ensure that CHP is meeting all its obligations.
- Clinical Management:
- Helps coordinate long-acting MAT medication delivery through local specialty pharmacy to brick-and-mortar sites for grant patients.
- Ensures the Mobile Health Unit (MHU) is stocked for any specific materials offered to patients through the grant.
- Coordinates with CHP administrative staff on the siting and schedule of the MHU.
- Fiscal management:
- Handles cash items for patients such as transportation vouchers.
- Tracks time spent by individuals on grant activities to report to the Grant Coordinator for submission to the state for reimbursement.
- Works with the Grant Coordinator to ensure accurate accounting and fiscal records are maintained.
- Clinical Nursing Role
- Updates and monitors the spread sheet of patients enrolled in the grant to ensure patients are not lost to follow up as they transition from the ER, medical hospitalizations, psychiatric or addiction-related hospitalizations, residential treatment programs, and court ordered programs. This might involve visiting patients before discharge, calling them, or on occasion with other team members making a home visit.
- Performs medication review and reconciliation and ensures ongoing seamless medication access for patients in the grant program.
- Tracks patients on MAT to ensure regularly delivered care with no lapse in access to MAT.
- Performs nurse visits for non-acute clinical concerns, chronic condition monitoring, MAT provision, and for hospital discharge medication reconciliation and triaging.
Nurse Case Manager/Program Manager Competencies: To perform the job successfully, an individual should demonstrate the following competencies:
- Administrative Competencies
- Data Management and Compliance
- Proficiency in data collection and reporting.
- Understanding of healthcare privacy law.
- Ability to work with intake and tracking systems for new and ongoing patient care.
- Program Management
- Ability to work with the Grant Director to coordinate grant-related activities to meet program objectives.
- Skilled in ensuring compliance with program guidelines and requirements.
- Financial Management
- Ability to manage cash items such as transportation vouchers.
- Familiarity with time reporting and grant reimbursement processes to work with the Grant Coordinator.
- Clinical Competencies
- Patient Transition Management
- Ability to track and follow up with patients transitioning from various care settings (e.g., ER, hospitalization, court-ordered programs).
- Proficient in discharge planning and coordination of care.
- Medication Management
- Skilled in performing medication reviews, reconciliation, and ensuring ongoing medication access.
- Familiarity with Medication-Assisted Treatment for addiction (MAT), including Sublocade and Vivitrol administration or experience with clinical nursing with willingness to learn.
- Clinical Care Delivery
- Proficiency in conducting nurse visits for chronic condition monitoring, hospital discharge care, and non-acute clinical concerns.
- Experience in MAT provision and patient care coordination or clinical experience with willingness to learn MAT.
- Patient Outreach and Engagement
- Effective communication skills, warmth, and a desire to help patients at vulnerable periods in their life.
- Ability to identify and address barriers to care and promote patient adherence through trust and rapport.
- General Competencies
- Collaboration and Teamwork
- Ability to work effectively with multidisciplinary teams, including administrative staff and healthcare providers.
- Skilled in coordinating with external organizations, pharmacies, and specialty providers.
- Organizational Skills
- Strong time management and prioritization skills to balance administrative and clinical duties.
- Attention to detail in tracking and documenting patient and program activities.
- Cultural Competency
- Sensitivity to diverse patient populations and ability to provide patient-centered care.
- Technical and Software Skills
- Proficiency in electronic medical records (EMR) systems.
- Familiarity with data entry and reporting tools.
Essential Skills and Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.Experience:
- 2+ years of clinical experience as a Registered Nurse working face to face with patients.
- Experience working with patients encountering social, economic, complex medical, behavioral health and/or substance use disorder conditions preferred.
- Understanding of hospital experiences and the needs after facility discharge.
- Administrative experience.
- Leadership experience preferred.
- Experience working in a community social service agency or state agency such as the Department of Mental Health (DMH), or other agency servicing those in need preferred.
- Effective case management and care coordination skills.
- Demonstrated ability to perform independently as a clinician with minimal supervision or assistance.
- Experience with self-scheduling of caseload preferred.
Education and Training:
- Registered Nurse required.
- Bachelors (or advanced) degree in nursing or a health care related field preferred.
- Graduate of a N.L.N. accredited nursing program.
- CPR is required every two years.
License, Certification C. & Registration:
- RN License as a professional nurse within MA.
- Active and valid driver's license.
Full-Time/Part-Time Full-Time Position BH Grant - Nurse Case/Program Manager Exempt/Non-Exempt Exempt Location CHP Neighborhood Health Center EOE Statement We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.