Nurse Care Manager RN (PT H)

PRIMARY PURPOSE OF JOB:

The Abilities First DD Health Home/ “Steps Forward” Nurse Care Manager (NCM) plays a pivotal role in managing the the population health needs and gaps in care of the DD Health Home population by adopting a whole-person approach that encompasses both physical and behavioral health aspects of individuals served in the DD Health Home program. The NCM will provide services reflecting the six core services of the DD HH program including care management, care coordination, health promotion, comprehensive transitional care, individual and family support, and referral to community and social support services.

The NCM will work closely with the DD Health Home Directors, Physician Consultants or APRNs, and the Specialized Healthcare Consultants, as well as other members of the individual’s health and care teams to assess current health needs, services, gaps in care and health assessment for each DD Health Home client assigned. The NCM will conduct health assessments, assist in developing and monitoring individual plan health goals and progress related to medical, and social determinants of health needs. The NCM is responsible for providing individual and population health education services. The NCM must provide a minimum of one core service for each assigned DD Health Home client per month. The NCM will utilize electronic health record systems to review, record health information and document health outcomes and services provided.

This description may not include all duties, knowledge, skills, or abilities associated with this position.

ESSENTIAL FUNCTIONS AND PERFORMANCE AREAS:

• Facilitate and participate in an organized, interdisciplinary team approach to care management for all assigned DD Health Home clients as well as the Abilities First DD Health Home overall population.
• The NCM will meet with individuals assigned to the Abilities First DD HH within the required timelines to explain to the individual the benefits and purpose of the DD HH program.
• The NCM must conduct a chart review within 30 days of enrollment of the individual into the DD HH program. In this process the NCM will become familiar with the clinical record and individual’s history and identify and prioritize health issues which may exist and begin the health care assessment and health plan process.
• The NCM shall complete a Metabolic Syndrome (MBS) screening with individuals as needed and per the timelines and required frequency as mandated by the DD Health Home contract and provider manual. The DD HH NCM will coordinate with the individual’s PCP to determine the recommended time frame for obtaining new lab values.
• The NCM must document services provided, clinical measures and data obtained, and reviews in each assigned individuals’ medical records; notes must, at a minimum, document the chart review occurred and be entered into the record within 72 hours of service.
• As part of comprehensive care management services, the DD HH NCM is responsible for completing standardized, comprehensive assessments of individuals’ health needs. The health information will be documented on a Health Screen form and entered into the appropriate electronic health record system/s.
• The DD HH NCM must conduct an annual face-to-face (video or in person) meeting with the individual and parent/guardian to review the health information, discuss healthcare concerns, and help translate health and wellness goals for inclusion in the individual’s DD HH healthcare goals.
• The NCM must monitor and regularly follow up on patients' health progress, adjusting treatment plans as necessary.
• As part of Care Coordination, health promotion and family support services, the NCM will help develop an overall person-centered health plan for each individual, which coordinates and integrates all clinical and social determinants of health-related needs and services and facilitates the individuals’ participation in the ongoing revision of their DD HH healthcare goals.
• The NCM will encourage active individual involvement through appropriate linkages, referrals, coordination, and follow up to needed services and support.
• The NCM will document individual services in the individual’s medical record including, but not limited to, comprehensive care management monitoring for care management gaps. Documentation must meet the DMH/MO HealthNet requirements.
• The NCM will utilize the DMH/DD identified system on a regular basis and are able to revise DD HH healthcare goals, as necessary.
• The NCM must perform timely medication reconciliation interventions and sign off on the medication reconciliation when complete, as mandated and defined in the DD Health Home contract and provider manual. A progress note must be entered in the individual record documenting the completion and results of the medication reconciliation. A transfer or hospital follow-up and medication reconciliation review must occur within 7 days for any DD HH enrollee that has been discharged from the hospital.
• The NCM will develop education to teach individuals how to manage their chronic illnesses and encourage healthy lifestyles.
• The NCM is responsible for overseeing the health trends of the entire population of individuals, following-up on identified trends impacting the health of the population, addressing high utilizers, participating in health education activities, including, as examples, topics on smoking cessation, disease prevention, and medication adherence.
• The NCM will coordinate care of DD HH participants enrolled in Managed Care Organizations (MCO) including keeping MCO apprised of individual’s needs; follow up with the individual’s interactions with the MCO during scheduled visits or phone calls; notify the MCO of individual’s discharge from the DD HH, as applicable.
• The NCM will maintain relationships and coordinate communication with individuals’ primary care physician. Assist the enrollee in acquiring a primary care physician when needed.
• The NCM must demonstrate the ability to identify potential abuse and neglect situations and follow protocol according to all applicable regulatory requirements.
• The NCM must have the ability to bend, sit, stand, and stoop.
• The NCM must have the ability to establish effective working relationships with co-workers and the public.
• NCM may not exceed the maximum 1 FTE: 200 individuals served ratio. This includes staff filling these roles on a part-time basis.
• Other duties as assigned

WORK ENVIRONMENT:

The work environment described here is representative of those an employee encounters while performing the essential duties and responsibilities of this job. The work environment is fast-paced and result-oriented, which presents multiple demands with frequent interruptions, constantly shifting schedules and priorities and simultaneous deadlines requiring the employee to be flexible, organized and cooperative. This position has access to confidential information. This requires the employee to maintain a high level of knowledge in confidentiality, agency policy and procedure, and applicable laws.

LEADERSHIP, ETHICS, AND PROFESSIONAL CONDUCT:

Abilities First employees are expected to model exemplary leadership at all times. This includes representing the agency in a positive, respectful, and professional manner through words, actions, and expressions. Employees are expected to communicate concerns, challenges, and differing perspectives through the established chain of command, using constructive, solution-focused, and professional language rather than judgmental or disparaging commentary. Abilities First expects staff to observe the highest ethical standards, maintain professional conduct above reproach and demonstrate unwavering integrity in all internal and external interactions.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Knowledge and experience teaching self-management
• Excellent telephone and interpersonal communication skills
• Ability to multi-task and prioritize, strong organizational skills
• Strong knowledge of medical terminology
• Strong knowledge of disease process/disease management and nursing care/body systems throughout the lifespan
• Computer experience required (Microsoft Office, Microsoft Teams)
• Electronic health record experience required

CORE COMPETENCIES:

Core competencies align with the Abilities First Core Values – OATH

One Team One Mission

• Contributing to Team Success – Actively participating as a member of a team to move the team toward the completion of goals.
• Engagement Readiness – Demonstrating a willingness to commit to one’s work and to invest one’s time, talent and best efforts in accomplishing organizational goals.

Accountable, respectful service

• Continuous Improvement – Originating action to improve existing conditions and processes, identifying improvements opportunities, generating ideas, and implementing solutions.
• Quality Orientation – Accomplishing tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
• Technical/Professional Knowledge and Skills – Having achieved a satisfactory level of technical and professional skill or knowledge in position-related area, keeping up with current developments and trends in area of expertise.

Transparent stewardship

• Decision Making – Identifying and understanding issues, problems, and opportunities; comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action or developing appropriate solutions; taking action that is consistent with available facts, constraints, and probable consequences.
• Planning and Organizing – Establishing courses of action for self and others to ensure that work is completed effectively.

Hold the rope

• Adaptability – Maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusting effectively to work within new work structures, processes, requirements, or cultures.
• Leadership Disposition – Demonstrating the traits, inclinations, and dispositions that characterize successful leaders; exhibiting behavior styles that meet the demands of the leader role.

EDUCATION, TRAINING AND EXPERIENCE REQUIREMENTS:

• (1) Registered Nurse who has a current Missouri or compact RN license recognized by the Missouri State Board of Nursing as an RN OR (2) Licensed Practical Nurse who has a current Missouri or compact LPN license recognized by the Missouri State Board of Nursing as an LPN.
• At least one year of professional nursing experience required.
• Experience in the IDD field is preferred, but not required.

ADDITIONAL REQUIREMENTS:

• Must have a valid Missouri Driver’s License, acceptable driving record and auto liability insurance that meets the requirements set by Abilities First.
• Must have secure and reliable high-speed internet in instance of working remotely.
• Must be able to pass a background screening.

PHYSICAL CONTEXT AND WORK ENVIRONMENT:

Reasonable accommodations may be made to enable individuals with disabilities to perform essential job duties.

• The work environment is usually a well-lighted, environmentally controlled indoor environment with moderate level of noise.
• Works in an office environment with the option for some remote work.

The statements herein are intended to describe the general nature and level of work being performed but are not to be seen as a complete list of responsibilities, duties, and skills required of personnel so classified. Also, they do not establish a contract for employment and are subject to change at the discretion of the employer.

Created: 12.13.2023; Updated: 11.07.2024; 12.31.2025