Nurse Care Manager

6 days ago


Philadelphia, Pennsylvania, United States Project Home Full time
Job Summary

The Registered Nurse (RN) Care Manager provides a holistic, trauma-informed, and patient-centered approach in caring for patients seen through Project HOME's Healthcare Services.

Key Responsibilities
  • Serves as a key member of an interdisciplinary team and instrumental to its success.
  • Works closely with participants, other Project HOME stakeholders, Project HOME Healthcare Services, and other primary care providers to provide coordinated intake assessments, goal setting, and plans of care.
  • Assess, triage, and respond to patients with acute, chronic, and preventive health and wellness needs.
  • Provides mentorship for PHHS nurse care managers who are new to the role.
  • Coordinates care with intensive emphasis during critical care transition points (e.g., from hospital/ED to home, from street to housing, from specialist to primary care, from primary care to hospice).
  • Participates in regular interagency, interdisciplinary care meetings for case review and discussion of evidence-based chronic disease management, integrated care best practices.
  • Conducts occasional mobile health visits with participants whose mental/physical/emotional conditions may prevent them from accessing care in a formal clinic setting.
Essential Duties and Responsibilities
  • Care Management: Coordinates with primary care providers, behavioral health providers, and other providers in implementing individual care plans, especially follow-up plans from ER or hospital discharges.
  • Information-sharing, goal setting with the participant, pre-visit planning, and after-visit follow-up, exploring gaps in care and working to eliminate them.
  • Educating participants and/or support system in areas such as harm reduction and/or recovery from substance dependence, disease-specific management, medication management, healthier lifestyle choices, stress reduction, chronic disease management, and pharmacological agents.
  • Facilitates individual or group sessions which provide education to staff and participants on health-related topics and activities that enhance recovery and self-care management.
  • Coordinates care with intensive emphasis during critical care transition points (e.g., from hospital/ED to home, from street to housing, from specialist to primary care, from primary care to hospice).
  • Participates in regular interagency, interdisciplinary care meetings for case review and discussion of evidence-based chronic disease management, integrated care best practices.
  • Conducts occasional mobile health visits with participants whose mental/physical/emotional conditions may prevent them from accessing care in a formal clinic setting.
Requirements
  • Bachelor of Science in Nursing (BSN)
  • 3 years of prior experience as a nurse care manager
  • Active RN license in Pennsylvania
  • BLS certification

Project HOME offers a competitive compensation package which includes health, prescription, dental, and vision coverage at minimum cost to our employees, company-funded life and disability insurances, paid parental leave, spending accounts, and 401K plan with 100% matching contributions up to 5% of compensation.


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