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Respite Registered Nurse Case Manager
4 months ago
**This is a NEW full-time position that will rotate between sites in Summit, Cicero, and LaGrange.**
**Brief Description**
This position is unique as it is a collaborative position between Pillars Community Health, Beds-Plus and Advent Health. The objective is to optimize health for those adults experiencing housing insecurity by improving access to primary care, appropriately referring patients for missed dental care, primary care, specialty medical care and providing individuals with appropriate behavioral health care.
The Respite RN Case Manager will work with PCH Physician or Nurse Practitioner to provide clinical services for the BEDS Plus Medical Respite program. RN will rotate between the Sokol Francis Summit Service Center, the Aloha Hotel in Cicero, and PCH health center sites.
**ESSENTIAL DUTIES AND RESPONSIBILITIES**:
- Supports the patient in developing self-management goals. Self-management goal setting is a collaborative, culturally appropriate approach and individualized/tailored to meet each patient’s needs, to help patients increase understanding of actions that affect their health, and to develop strategies to live as fully as possible.
- Assesses vaccine status and help patients get scheduled for any missing vaccines, such as COVID 19, Flu, Td, etc.
- Screens for social determinants of health and connects patients with appropriate resources.
- Conducts discharge planning upon admission, ensures alignment with discharge indicators and expected plans after respite care has ended.
- Identifies barriers to accessing health care and related services outside of the medical respite program.
- Assists patients with navigating health systems and establishes an ongoing relationship with primary care providers and patient-centered medical homes.
- Coordinates transportation to and from medical appointments and support services.
- Facilitates patient follow up for medical appointments and accompanies the patient to medical appointments, when necessary, to aid the patient in addressing their conditions and symptoms, and advocates for preferences for care.
- Ensures communication occurs between medical respite staff and outside providers to follow up on any changes in patient care plans.
- Completes referrals and coordinates follow-up to substance use and/or mental health programs, as needed.
- Completes referral for long-term case management, when appropriate and available.
- Connects and engages with community health workers and peer support services, as indicated.
- Ensures active medication list is transmitted from the hospital. Requests medication list from any primary care provider or pharmacy that the patient has visited in the last 6 months.
- Ensures patients have access to medication or assists patient with coordinating access to medications while at the respite clinic.
- Communicates with primary care or other providers medical list.
- Provides support to patients by making appointments with external primary care, specialists, diagnostic testing, and other therapies as a part of care coordination activities.
- Assists patient with pillboxes, reminders to take medications and/or use of blister packs.
Other:
- Attends all meetings as required.
- Adheres to all organization policies and procedures.
- Adheres to OSHA guidelines for a safe work environment.
- Follows all rules required to comply with confidentiality and HIPAA policies.
- Complies with all applicable laws, including but not limited to medical records laws, HIPAA, OSHA and the corporate compliance program.
- Ensures compliance with organization health & immunization/vaccination requirements.
- Performs other duties as assigned.
**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 an individual with a disability to perform the essential duties and responsibilities.
**EDUCATION, LICENSE, EXPERIENCE**
Bachelors of Science degree in Nursing required. IL RN License required. At least 2 years of clinical nursing experience required. Experience in a not-for-profit organization preferred. Experience in a hospital or community health center preferred. CPR Certification required.
**DEMONSTRATED COMPETENCIES**
- Practices cultural humility with a commitment to reducing barriers to healthcare for marginalized and/or low-income individuals.
- Compassionate, empathetic, and respectful
- Active listener
- Demonstrates integrity and self-confidence.
- Resourceful, persistent, persuasive, and assertive.
- Ability to perform basic mathematical computations using whole numbers, fractions, decimals.
- Highly organized with ability to multi-task and willingness to learn new tasks
- Excellent oral and written communication and interpersonal skills
- Ability to track and input data.
- Ability to work within a team environmen
