POSITION SUMMARY 

Under the general direction of the Healthcare Home Director and Supervisor, the Nurse Care Coordinator provides health and wellness services to people with chronic health conditions and behavioral health disorders. This individual serves as a member of Healthcare Home (HCH) to assist Beacon Mental Health Services with the integration of daily clinical operations to promote and encourage wellness, healthy lifestyles, preventative care, and educate on how to better manage their chronic health conditions. The Nurse Care Coordinator is involved in the enhanced culture of behavioral and medical wellness for consumers of the agency. This individual will also assist with outreach and coordination of the Disease Management (DM) Projects. DM populations consists of Medicaid-eligible adults who have a serious mental illness or substance use disorder, high medical costs, and are not currently receiving behavioral health services.

ESSENTIAL DUTIES AND RESPONSIBILITIES
The essential functions include, but are not limited to the following:
• Provides active outreach to clients who are enrolled in Disease Management program and begin to develop a working alliance towards understanding their individual concerns and needs.
• Provides instruction and/or case management services to consumers who have been diagnosed with physical health conditions or may be at high risk for developing health conditions.
• Acts as the DM3700/Case Management liaison.
• Acts as the Enrollment specialist for DM3700 services, CPRP services, and HCH services.
• Champions healthy lifestyle and wellness principles, including tobacco prevention and cessation, nutrition, and physical activity. Supports preventative care efforts on healthcare issues and alcohol and drug abuse.
• Trained as CyberAccess liaison with the Division of Behavioral Health.
• Participates in the collection and documentation of metabolic screening data through point-of-care testing and coordination with primary care providers in the community. 
• Provides instruction and/or case management services to consumers who have been diagnosed with physical health conditions or may be at high risk for developing health conditions.
• Works with consumers and families utilizing motivational interviewing, evidenced-based practices and interventions which support healthy lifestyle principles and goals.
• Maintains training and certification in Smoking Cessation and provides treatment for persons seeking to stop using tobacco and related products.
• Coordinates with the Healthcare Home team for population health management related to chronic health conditions and for connection to Healthcare Home services when appropriate.
• Coordinates with the Medication Services team to aid in completion of Metabolic Syndrome Screenings and vitals and in appropriate education and connection to services. Complete metabolic screening data entry.
• Coordination with case management teams, peer support staff, and other teams for a holistic approach to consumer care.
Provides back-up to the Healthcare Home team to which this role is assigned.
• Primary liaison of Swope Health Maple Woods services while providing updates to the HCH Director, HCH Supervisor, and Clinical Director. Assists consumers in accessing primary and specialty care needs.
• Uses health information tools (AvatarNX, CareManager, Cyber Access, KHIN, CIMOR and other designated systems).
• Oversight of monitoring for treatment gaps via population health.
• Establishing organizational priorities for disease management and improving health status.
• Participates with post hospital discharge for individuals enrolled in HCH.
• Facilitate the multi-disciplinary teams’ reviews of monthly care management and hospital admission reports.
• Assist with appointment scheduling and tracking individual’s services.
• Provides health and wellness coaching to people with chronic health conditions and behavioral health disorders. Provides instruction and coaching to consumers and their families on healthy lifestyle practices to achieve desired health and wellness goals.
• Other duties and or responsibilities as assigned.

MINIMUM QUALIFICATIONS (KNOWLEDGE, SKILLS, AND ABILITIES)

Education/Certifications:
• LPN required
• Case Management Experience preferred
• CPR/First Aid certification required
• Active driver’s license and minimum state-required insurance

Experience Required:
• 3 to 5 years of position-related experience
• 5+ years’ experience preferred.

Required Knowledge:
• Knowledge gained through prior employment and/or education related to targeted health and wellness promotion, along with chronic disease processes, especially related to obesity, diabetes, hypertension, COPD/asthma, and heart disease.
• Experience with tobacco cessation education, nutrition, and lifestyle principles preferred.
• Experience in behavioral health and/or substance use fields preferred.

Skills/Abilities:
• Excellent phone and verbal communication skills.
• Proficient computer skills to include Microsoft Office Applications and Outlook.
• Experience with electronic medical records.
• Proficiency with point-of-care metabolic screening testing and vital sign collection.
• Excellent patient/consumer education skills.
• Excellent organization and prioritization skills.
• Motivational interviewing experience preferred.
• Ability to use basic office equipment and type proficiently.