Healthcare for the Homeless Charge Nurse Position

The Healthcare for the Homeless Registered Charge Nurse will provide care management to targeted high-risk unhoused patients who are at risk for poor health outcomes. The Registered Nurse Case Manager will act as a Charge Nurse for the Patient Care Team to identify barriers to care and to understand the interplay between physical health, mental health, social issues, and resource needs, and will encourage patients to actively engage in their own health and work toward maintenance or improvement of health status by creating care plan objectives.

• Provide Case Management to patients determined high risk based upon PCMH guidelines (high ER use and hospitalizations, identified chronic disease). These patients are targeted as likely to benefit from effective care management, using criteria applied to the patient population.
• Perform patient assessment and develop individual care plans, including evaluating the patient's medical, psychological, social, financial, and educational/employment history, any history of substance abuse, and any services currently being received by the patient.
• Perform office, in-home, and field visits to targeted patients; maintain targeted high-risk caseload on an ongoing basis.
• Provide ongoing emotional support and act as an advocate for the patient within the patient care team and other community support services and organizations.
• Work with each patient to identify individualized clinical and personal healthcare goals such as improving therapeutic outcomes; work to set and document attainable long- and short-term goals for individual progress; follow up with patient during transition to ensure medical needs are being met.
• Assess patient needs, answer questions, and provide education.
• Respond to patient's questions and comment in a courteous and timely manner.
• Communicate and coordinate regularly with appropriate others to maximize the effectiveness and efficiency of interagency operations and activities.
• Identify and refer clients to appropriate community resources and programs; enhance working relationships with other community agencies and referral sources.
• Obtain or verify necessary patient information such as medical records, verification of employment, and a release for all patient records.
• Coordinate, monitor, and work closely in conjunction with the Patient Care Team, in a Patient Centered Medical Home model, to ensure effective quality and coordination of services received.
• Provide support to and motivate patients in following treatment plans and achieving life goals.
• Track high-risk patient outcomes using established outcome measures and design and implement strategies to improve outcomes.
• Review patient medical records regularly and follow up with outside care providers, agencies, and community service providers to ensure that the patient receives appropriate assistance.
• Utilize an electronic medical record to retrieve patient information and to develop and enter patient data into a computer database and/or spreadsheet. Accurately and appropriately document patient information in a timely manner and in accordance with RiverStone Health clinic policies and procedures.
• Provide crisis assistance as necessary. Access appropriate Federal, State, County, and local programs, community service providers, and agencies, and other resources to meet client needs.
• Provide culturally sensitive care and services to patients, maintaining awareness of social and/or medical issues, and a willingness to work with underserved, under-or uninsured, and low-income patients.

• Recognize and educate staff that managing patient care is a team effort that involves clinical and nonclinical staff (e.g., physicians, nurse practitioners, physician assistants, nurses, medical assistants, educators, front desk staff, schedulers, etc.) interacting with patients to achieve stated objectives.
• Attend meetings, conferences, workshops, and training sessions and review publications and audio-visual materials to become and remain current on principles, practices, and new developments in assigned work areas.
• Stay abreast of social and/or medical issues relating to the underserved, uninsured, and low-income patients.
• Use logical and creative thought processes to develop solutions according to written specifications and/or oral instructions.
• Provide needed information and demonstrations concerning how to perform certain work tasks to new employees in the same or similar class of positions.
• Keep immediate supervisor and designated others accurately informed concerning work progress, including present and potential work problems and suggestions for new or improved ways of addressing such problems.
• Ensure program compliance guidelines, contract/grant requirements, and/or accreditation standards are met.
• Ensure program, and agency policies and procedures are being followed.
• Generate and interpret reports and other pertinent information to share with staff and utilize for quality improvement strategies.
• Assist with the development of quality care and patient/client satisfaction.
• Identify and support quality Improvement initiatives.
• Assess and develop strategies to ensure program success.
• Investigate complaints and suspected violations.
• Lead productive and motivational team meetings.
• Promote teamwork and collaboration among staff.
• Order supplies and oversee inventory management.
• In absence of program manager, coordinate the day-to-day work of clinic staff.
• Participate in recruiting, hiring, onboarding, and coaching of team members.
• Work closely with community partners to build relationships and ensure communication and collaboration. Make presentations to community partners, local state, regional, and national organizations as appropriate.
• Actively promote HCH services in clinic and outreach settings within the community.

Minimum Qualifications:

• Currently Licensed Practical Nursing and able to sit for NCLEX for RN licensure within 6 months or
• Licensed as a Registered Nurse in the State of Montana in good standing
• Considerable patient care and nursing experience: 3 to 5 years
• Any combination of experience and training which provides the equivalent scope of knowledge, skills, and abilities necessary to perform the work

Preferred Qualifications:

• Medical terminology training or experience
• Experience working with underserved population
• Experience working in a customer service environment

Required Certificates, Licenses, Registrations:

• Current driver's license in the state of MT
• Licensed as a Registered Nurse or LPN in the State of Montana in good standing or
• ICS Training 100, 200 & 700 (completed after hire)

Knowledge, Skills, and Abilities:

• Computer literacy, in Microsoft Office Suite.
• Ability to maintain a calm and positive demeanor during difficult client interactions.
• Ability to display non-judgmental and empathetic listening skills.
• High degree of detail-oriented skill level.
• Knowledge and understanding of protected sensitive patient health information (HIPAA) and confidentiality.
• Ability to work collaboratively and maintain a positive work environment.
• Ability to perform job duties with integrity and innovation to ensure completion and a high level of quality.
• Ability to understand and adhere to required administrative policies and procedures.
• Excellent communication skills to ensure efficiencies and quality customer service.
• Ability to accurately access the physical, emotional, and psychological state of clients.
• Ability to communicate effectively with others, both orally and in writing, using both technical and non-technical language as appropriate to the situation.
• Ability and willingness to quickly learn and use new skills and knowledge brought about by rapidly changing information and/or technology.
• Knowledge of community resources, services, and programs available to assist clients.

Customer Service Excellence:

• Doing things right the first time
• Making people feel welcome
• Showing respect for each customer
• Anticipating customer needs and concerns
• Keeping customers informed
• Helping and going the extra mile
• Responding quickly
• Protecting privacy and confidentiality
• Demonstrating proper telephone etiquette
• Taking responsibility for handling complaints
• Being professional
• Taking ownership of your attitude toward Service Excellence

Supervision:

None

Physical Demands and Working Conditions:

Required to stand, walk, and sit; talk or hear, both in person and by telephone; use hands to finger, handle, or feel objects or controls; reach with hands and arms.

Regularly required to stoop, kneel, bend, crouch, and lift up to 25 pounds frequently and 50 pounds occasionally; expected to ask for help from a colleague when assistance is needed.

Specific vision abilities required by this job include close vision, distance vision, depth perception, color vision, and the ability to adjust focus.

The position is regularly exposed to biological pathogens and contagious diseases where Personal Protective Equipment (PPE) and special precautions must be taken due to reduce exposure and mitigate risk.

Create and maintain a safe/secure working environment by adhering to safety, security, and health requirements. Integrate injury, illness, and loss prevention into job activities by attending any necessary training and implementing best practices.

Freedom to Act & Decision Making:

Work is structured by public health regulations and established medical practices.

Decisions directly affect the quality of services provided to the public.

Communications & Networking:

Daily written and verbal communication with patients, clients, and other staff.

Work directly with other team members to provide quality customer service for patients and customers.

Budget & Resource Management:

N/A