PRN Health Home Nurse

We are currently in search of an experienced PRN Health Home Nurse for our Brooklyn, MD location. This position is accountable for designing and maintaining systems to ensure the continuity of care between the OTP program and somatic and behavioral healthcare providers both within CCG and in the community, as well as developing processes to assist consumers in the development and maintenance of healthy lifestyles and illness management skills.

Schedule: PRN (as needed). Preferred hours between 530am - 2pm and rotating Saturdays 6am to 10am

Essential Duties and Responsibilities:

• Acts as a comprehensive care coordinator for participants assigned to care, assessing their needs accordingly and facilitating communication amongst other clinicians providing care
• Leads practice transformation based on Population Health principles and state/accrediting body requirements
• With agency leadership, acts as a "champion" for the Population Health philosophy and provides education to staff
• Develops and maintains working relationships with primary and specialty care providers including inpatient facilities and emergency departments
• Monitors Population Health performance at the population and participant level and implements improvement efforts via statistical data gathering
• Designs and develops prevention and wellness initiatives
• Establishes the effective use of patient registries (CRISP and eMedicaid) as applicable to manage specific patient populations and to improve disease and population health outcome measures
• Collaborates/consults with specialty practices to identify data needs related to care coordination
• Monitors participants monthly visits to ensure the appropriate services are delivered
• Oversees the entering of all required data
• Performs comprehensive assessments of physical, emotional, psychosocial and environmental needs of participants and develop care plans for all assigned Population Health enrollees around physical health or social goals
• Facilitates health education groups
• Assesses, coordinates and implements service planning needs of assigned persons
• Evaluates/assists in evaluation of appropriateness of plan of care and revises on an ongoing basis with communication to all other disciplines
• Reviews result of laboratory tests and other diagnostic procedures and reports to the nurse practitioner or psychiatrist
• Identifies significant clinical findings, makes conclusions and intervenes appropriately under the direction of the nurse practitioner consultant
• Compares ongoing outcome data to baseline data to monitor clients
• Initiates client education based on identified learning needs of the client and/or those providing care and documents appropriately
• Supports and monitors compliance of the individual including checking of prescription labels and storage
• Consults with behavioral health staff about participants identified health conditions
• Attends treatment team meetings with behavioral health staff to plan and coordinate care
• Assists in contacting medical providers & hospitals for coordination of care efforts
• Supports medical and nursing team with admissions
• Provides training on medical diseases, treatments, & medications to health home participants
• Assists in the training and education of OTP staff regarding population health services
• Provides training on medical diseases, treatments, & medications to behavioral health staff, as indicated
• Takes action to correct observed risks to patient safety
• Reports adverse events and near misses to supervisor
• Develops effective working relationships and maintains good communication with other team members. Identifies possible risks in processes, procedures, devices and communicates the same to those in charge
• Provides dispensing coverage and other needed dispensing / med room tasks as needed. This may be recurring scheduled dispensing coverage, as backup coverage for dispensing nurses, or for emergency coverage
• Other duties as assigned