INTRODUCTION

Under the supervision of the Nurse Manager, the Registered Nurse (My Health GPS) provides clinical and programmatic support for high-risk patients receiving complex care management services. Part of the RN's job is to provide direct care management to particularly vulnerable populations while also providing programmatic oversight and guidance to health center-based care teams providing care coordination to similar populations. The RN will oversee population health services with regards to clinical functionality, including but not limited to direct patient care, oversight of clinical care coordination and care management staff and activities, and outreach services available to patients receiving care management. The RN serves as an integral member of an interprofessional care management team working alongside medical providers, clinical nurses, nutritionists, and social service staff to meet the needs of our patients located in a variety of Washington, DC settings, including the hospital, primary care clinics, patient homes, homeless shelters, and various other community settings.

MAJOR DUTIES/ESSENTIAL FUNCTIONS

Essential and other important responsibilities and duties may include, but are not limited to the following:

• Utilizes nursing theory and approaches to improve and impact health outcomes for patients enrolled in MHGPS
• Conduct comprehensive assessment of patients' physical, mental, and psychosocial needs.
• Utilizes the dimensions and competencies of care management: Support for patient self-management; education and engagement of the patient and their family; cross-setting communication and care transitions; coaching and counseling of patients and families; the nursing process including assessment, plan, implementation/intervention and evaluation, a proxy for monitoring and intervening in patient care; teamwork and collaboration; patient-centered care planning, population health management and advocacy.
• Develop care plans to prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, and minimize hospital and ED utilization.
• Utilize behavioral strategies, help patients adopt healthy behaviors, and improve self-care in chronic disease management. Promote self-management goals.
• Manage own panel of at-risk patients not being followed by care teams to include but not limited to: patients recently hospitalized, patients who have been lost to care and patients needing intensive care management activities.
• Monitors pediatric and adult screening adherence, lab results, clinical referrals and performs medication reconciliation for patients enrolled in MHGPS.
• Assists in designing and implementing protocols and work flows to support six core activities of DCHF's My Health GPS activities: comprehensive case management, care coordination, health promotion, comprehensive transitional care from inpatient to other settings, individual and family support services, and referral to community and social support services.
• Serves as a connection with hospital discharge planners in District of Columbia hospitals for the purposes of establishing standardized discharge procedures for patients who require complex care management.
• Facilitates timely post-hospitalization follow-up working with area hospitals, specialists and primary care teams to improve patient's recovery and long-term health outcomes.
• Provides instruction, teaching and mentorship to all members of the care management team as it relates to achieving programmatic goals and outcomes; provides clinical oversight and guidance as it relates to MHGPS patients.
• Performs chart audits to ensure quality of services rendered.
• Assists health center leadership in planning and executing interprofessional case conferences, team meetings and care management rounds.
• Addresses clinical emergencies according to protocol or general standard of care guidelines.
• Attends appointments and performs outreach when necessary to provide medical translation and patient advocacy.
• Assists with the creation of a care management curriculum for the purposes of training and professional development; Identifies training needs for staff providing care coordination and care management services.
• Enters and maintains electronic records, reviews notes compiled by others as needed, and compiles/completes reports and other program documentation in a timely manner (e.g., tracks via progress notes, etc.); performs other administrative responsibilities as needed.
• Assists Quality Director in implementing and monitoring population health outcomes.
• Partners with site-based staff in QI initiatives as they pertain to care coordination and care management.
• Utilizes risk stratification and acuity scores to assign patients to care teams and provide operational support as needed.
• Plays a consistent and active role in identifying project inefficiencies and finding collaborative solutions to the problems.
• Attends relevant training as necessary to maintain professional certification and/or knowledge.
• Adheres to Unity's HIPAA guidelines and ensures the appropriate handling of sensitive information.
• Completes special projects specific to the function of the program and/or organization.
• Performs other duties as assigned within the scope of position expectations.

MINIMUM QUALIFICATIONS

• Graduate of an accredited school of nursing with a Bachelor's Degree. Masters of Public Health (MPH) preferred.
• Registered Nurse licensed to practice in Washington, DC.
• Maintains current CPR certification.
• Two (2) years of experience providing clinical services; experience in a hospital and/or community/outpatient setting.
• Project or case management nursing experience preferred.
• Experience working with patients living with chronic health conditions including HIV, depression, hypertension, hyperlipidemia, and personality disorders preferred.
• Expertise in community health, discharge planning, chronic disease management a plus.
• Three (3) years of working independently with minimal oversight in a clinical setting a plus.

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES

• Demonstrated ability to communicate and drive outcomes across professional disciplines, organizations and clinical settings especially on behalf of medically and socially vulnerable populations.
• Ability to effectively provide clinical care to socially and medically complex patients in a variety of non-traditional settings; experience in serving in poor, urban environments; familiarity with Washington, DC is preferred.
• Ability to utilize health information systems, including: EMRs; data reporting and disease surveillance registries; health information exchanges; prescription drug monitoring platforms; and population health management platforms.
• Ability to assess clients for needs related to treatment education, risk reduction, or prevention in person and over the phone.
• Ability to conduct sensitive, empathetic interviews that respect the dignity and diversity of clients.
• Strong organizational, record-keeping, and writing skills, with attention to detail and the ability to work quickly, independently and responsibly in a fast-paced clinic setting.
• Demonstrated ability to train, educate and oversee staff providing direct care to clients on a myriad of issues.
• Exceptional interpersonal and organizational skills, with attention to detail required; strong oral/written communication skills are a must.
• Ability to work collaboratively in a team and manage multiple priorities, utilize effective time management skills, and exercise sound administrative and clinical judgment.
• Proven ability to work collaboratively and productively with clinicians, administrators, patients, and other individuals from various backgrounds and skill sets.
• Requires the ability to travel to multiple office locations.

SUPERVISORY CONTROLS

The position reports to the Nurse Manager

GUIDELINES

The position abides by all rules and regulations set forth by applicable licensing and regulatory bodies, as well as UHC policies and procedures.

PERSONAL CONTACTS

The position requires contact with staff at all levels throughout the organization. There are also external organization

relationships that may be part of the work of this individual.

PHYSICAL EFFORT AND WORK ENVIRONMENT

• Must be physically able to sit, stand, and walk for long periods of time. Be able to bend, lift, and carry files from one location to another.
• Must have visual acuity and the ability to differentiate colors, and sustain long periods of computer usage.
• May sit for prolonged periods of time at a desk or in an automobile and/or may use the telephone for long periods of time.
• The office environment may be stressful with multiple, time-sensitive tasks to be accomplished within a short period of time.
• Must be able to work any time of the day, independently with minimal supervision, be capable of making sound business decisions, be detail oriented, alert, and self-motivated.
• Must be able to effectively manage difficult situations, staff, and customers.
• The ability to work at a computer and analyze data.
• See the attached ADA Checklist.

RISKS

The position involves everyday risk and discomforts, which require normal safety pre-cautions typical of such places as offices, meetings, training rooms, and other UHC health Care Sites. The work area is adequately lit, heated, and ventilated. All medical services shall be provided according to medically accepted community standards of care. The employee shall provide evidence of recent (within the past twelve (12) months) health assessment that includes a PPD and/or chest x-ray results.

The statements contained herein describe the scope of the responsibility and essential functions of this position, but should not be considered an all-inclusive listing of work requirements. Individuals may perform other duties as assigned including work in other areas to cover absences or relief to equalize peak work periods or otherwise balance the workload.