Patient Centered Health Home (PCHH) Nurse Case Manager

POSITION SUMMARY: Performs the duties required to provide case management services, advocacy and triage to insured, uninsured, and homeless clients. Assist with policies and procedures, monitoring and tracking in accordance with the Missouri State Board of Nursing Practice Act.

Education: Bachelors of Science in Nursing required.

Experience: Minimum of three (3) years’ experience as a Registered Nurse in primary care, community health setting, case management or related field.

Skills and Abilities:

* Possess initiative, flexibility, and self-motivation.
* Good oral and written communication skills.
* Ability to motivate clients and subordinate staff.
* Capable of being a team member as well as a team leader.
* Educate both adults and children effectively.
* Good computer skills including the use of word processing and e-mail software.
* Ability to maintain confidentiality.
* Knowledge and utilization of insurance plans accepted by Affinia Healthcare.

Residency and Transportation Requirement: Must possess a valid driver’s license and automobile with insurance coverage as required by the State of Missouri.

License(s) Certifications(s) Required:

1. Licensed as Registered Professional Nurse in the State of Missouri
2. CPR certification required.

Essential Functions:

* Provide case management services to eligible clients and targeted populations (i.e. perinatal, asthma, lead, high risk infants, homeless, etc.) Advocate, and encourage the client to be self-reliant.
* Develop, implement and follow-up on nursing care plans to provide nursing services in the primary care and community setting.
* Provide health education and counseling to clients in their homes, school setting, or in clinical setting. Identify and report abnormal behavior, signs and symptoms of illness to health care provider.
* Coordinate and refer clients to resources, track their use of these resources. Coordinate medical, dental, social service, housing visits and other referrals with transportation services.
* Assist OB/GYN Clinical Nurses with the assessment of prenatal clients for risk status of unborn child for lead poisoning; identify prenatal clients eligible for home lead remediation and make appropriate referrals to lead program.
* Initiate the referral of high-risk patients and families for special services, team management. Track the patient’s referral outcomes (i.e. abnormal lab result, patient no show, etc) and initiate follow-up according to Affinia Healthcare’s protocol.
* Coordinate necessary follow-up health services following health, dental, lead and other screenings.
* Complete health-related forms and computer data entry. Document nursing activities accurately and in a timely manner. Assist in implementing, maintaining and updating patient racking system and compiling monthly/required statistical and narrative reports.
* Acts as the departmental preceptor, providing orientation and training for new nurses.
* Assist the supervisor in medical record audits; conducts monthly tracer activities.
* Assist the supervisor with nursing evaluations, by observing their performance in the community and in the clinic (prenatal intake) setting.
* Assist with the supervision, training and evaluation of Community Health Nurse Assistants.
* Provide orientation to facility and equipment to all nursing school students assigned to organization for clinical experiences.
* Provide feedback regarding student’s progress, identify problems, and suggest ways to resolve issues; evaluate student experience with students and faculty.
* Perform other duties as assigned.

NOTE: Affinia Healthcare is a Covid-19 Vaccine Mandated Employer. All employees of Affinia Healthcare are required to be vaccinated for Covid-19.

NOTE: SMOKING IS PROHIBITED IN THE WORK ENVIRONMENT

NOTE: ALL APPLICANTS MUST PROVIDE CONTACT INFORMATION FOR THREE REFERENCES

#### AN EQUAL OPPORTUNITYSERVICES PROVIDED ON A NON-DISCRIMINATORY BASIS

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