RN Case Manager - Hepatitis C Program

SUMMARY:

The RN Case Manager will work providers and team nurses to assure that the patients referred for Nursing Case management receive patient assessment, care planning, education, follow up and support in developing and achieving their health-related self-management goals; and best health outcomes.  The RNCM collects, maintains, reports and follows up on related medical data. She/he assists in the development of day-to-day management and long-term planning for the patient’s care.  The RNCM collaborates with health center providers and multidisciplinary professionals in providing for physical, psychological and/or social support for assigned patients and families.  She/he identifies and establishes relationships with community resources which can contribute to the network of care for patients.  The RNCM meets the requirements of the designated funding source in achieving required program goals.

The RN Case Manager – Hepatitis C supports the provision of coordinated medical and integrated behavioral health services to patients within the Harm Reduction Program working primarily with patients infected with the Hepatitis C Virus (HCV) and those who access Syringe Services.  Under the direction of the RN Director of Community Programs, the HCV RN utilizes program criteria to foster timely patient access, clinical assessment, lab testing, immunizations, service referral, and coordination of necessary data.  He/She works closely with Community Health Counselors to facilitate treatment and referrals.  He/she promotes patient understanding and utilization LCHC services, within the framework of the Patient’s Plan of Care and Program requirements.  The HCV RN participates in a variety of activities designed to educate community members, increase program visibility and increase use of the Lynn Community Health Center Primary Care Services by the targeted patient population.

The RNCM may participate in community outreach efforts as appropriate and as assigned.  This may include serving as a health consultant for the Lynn Public Schools, local day care centers, after school program, day camps or other community related organizations; providing such services as programmatic consultation, preparation/review of health-related policies and documentation or participating in health screenings, health education programs or counseling at health fairs and other similar community events.

Core Responsibilities:

  • Respects and maintains confidentiality in all aspects of care including use of electronic information.
  • Treats all patients in a welcoming and professional manner.
  • Demonstrates professionalism by appropriate attire, attendance, attitude, and behavior within the clinical setting.
  • Contributes to the team effort by supporting all team members and maintaining an open and positive attitude.
  • Welcomes new employees to the team by assisting with their orientation to the team and mentoring them, as requested.

DUTIES AND RESPONSIBILITIES:

  • Establish contact with patients appropriate for RN Case Management due to diagnosis, treatment regime, risk status, compliance, recent ER usage or Grant specified target group criteria.
  • In collaboration with the PCP, Team RNs, Clinical Pharmacist, other Providers, patient and family formulate a plan of care that supports best practice and guides the patient in achieving identified/revising Self Management goals. This plan may include medication management, diet counseling, exercise, referral for specialty care, education for proper use of medical equipment or supplies, update of immunizations, group or individual education and support.
  • Coordinate with other departments and agencies to best meet patient needs (i.e. Enrollment, Social Services, WIC, HAWC, BH, SBHC, Dental, Eye, Pharmacy etc.)
  • Assure that patients are scheduled for follow up, lab or other pertinent visits and receive periodic phone calls to support their health maintenance activities.  Provide for follow up of no shows.
  • Consistently use the learning assessment, appropriate teaching guidelines, plan of care, EHR/EPM to review and document patient interventions.
  • Develop and utilize patient case registry and data collection programs to track, record and summarize patient information for funding sources.
  • Participate in all applicable departmental, health center, and funding source meetings, educational programs, in-service training and/or conference calls to maintain professional and technical knowledge.
  • Participate in the development and evaluation of applicable protocols, procedures and decision support tools.
  • Collaborate and provide support to the team nurses, providers and staff regarding Case Managed Patient issues.
  • Obtain required specimens and perform or request diagnostic tests.  Ensure that provider and patient are notified of abnormal results.
  • Perform functions as a Team RN or other related duties as required or assigned.
  • Triage patient phone calls and identify need for urgent care, making appropriate patient care decisions.
  • Maintain accurate patient records by recording nursing observations and interventions appropriately and within scope of practice.
  • Perform or assign tasks associated with maintaining a properly stocked, safe and clean clinical environment.
  • Participate in the development of team goals, objectives, protocols and procedures.

SPECIFIC DUTIES AND RESPONSIBILITIES:

  • Participates in direct and indirect patient care for patients who are HCV positive or who access Syringe Services including telephone triage, assessment, intervention, health maintenance, and health education, health counseling, and planning activities, under the direction of the RN Director of Community Programs.
  • In accordance with provider written orders, LCHC standing orders, LCHC Medication Safety policies and program guidelines safely administers and documents immunizations and /or other medications.
  • Tracks and reviews laboratory and other pertinent diagnostic testing, informing medical provider of all results in a timely manner.
  • Establishes a positive professional relationship with assigned patients in order to foster the patient’s understanding of his/her health status and associated plan of care.
  • In collaboration with the PCP, Team RN’s, Clinical Pharmacist, other Providers, patient and family formulate a plan of care that supports best practice and guides the patient in achieving identified/revising Self-Management goals.
  • Obtain required specimens and perform or request diagnostic tests.  Ensure that provider and patient are notified of abnormal results.
  • Utilizes all equipment safely and reports breakages appropriately.
  • Accurately documents observation, pertinent patient conversations and action in the Electronic Record and in any grant required forms/logs.
  • Collaborates with other programs serving the patient in order to foster seamless care.
  • Assure that patients are scheduled for follow up, lab or other pertinent visits and receive periodic phone calls to support their health maintenance activities.  Provide for follow up of no shows.
  •  Develop and utilize patient case registry and data collection programs to track, record and summarize patient information for funding sources.
  • Under the direction of the RN Director of Community Programs, coordinates patient care with other departments or providers within the health center including social service, enrollment, referral, Community Health Counselors, BH, HIV, WIC, SBHC, and Dental etc. to assure comprehensive health services for assigned patients.
  • Perform other duties as required or assigned.
  • Attend all pertinent LCHC or grant related meetings or trainings.  Maintain own professional or technical knowledge by attending educational workshops.

Requirements

QUALIFICATIONS:

  • Bi-lingual in Spanish, French or other language spoken by LCHC patients is preferred
  • History of good attendance and positive work attitude
  • Demonstrated ability to work with culturally diverse and vulnerable populations
  • Graduate of accredited practical nursing program and current Massachusetts RN licensure
  • BLS certification
  • Knowledge of Substance Use Disorder
  • Knowledge of Hepatitis C

SPECIAL REQUIREMENTS:

  • The essential duties of this position present risk of exposure to airborne infection, body fluids and blood borne pathogens. 
  • Annual BBP Training is required. 
  • Up to date immunization and annual TB testing is required. 
  • Hepatitis B and annual flu immunization are strongly recommended. 
  • All necessary vaccines are available at no charge at the health center. 
  • A declination must be signed if the Hepatitis B or other recommended vaccines are declined.
  • Results of inquiry to Criminal Offender Record Investigation (CORI) must be acceptable under health center standards.

Customer Service:

  • Demonstrates an understanding of customer service principles by successfully completing on-line Customer Service Training.
  • Utilizes the principles of customer service when interacting with patients/clients, team members and staff from other departments.
  • Appropriately handles or seeks support when customer service breakdowns occur.

Cultural Competence:

  • Demonstrates an understanding of customer service principles by successfully completing on-line training on Cultural Competence.
  • Utilizes an appreciation of and respect for diversity when interacting with patients/clients, team members and staff from other departments.
  • Responds appropriately or seeks support when confronted with cultural biases or conflicts.

Emergency Situations:

  • Is aware that in order to respond promptly and appropriately to emergencies, any staff member may be assigned duties that differ from those in the job description, or may be assigned temporarily to a different location or schedule.
  • Understands that all staff should have a Personal Emergency Plan in place to best respond to his/her job responsibilities should a health center emergency arise.

Lynn Community Health Center (LCHC) provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, LCHC complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, and transfer, leaves of absence, compensation and training. LCHC expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of LCHC’s employees to perform their job duties may result in discipline up to and including discharge. 

Job Posting Id #18-018 (Part time 20 hours per week)

Hours

Part-Time