POSITION SUMMARY 

The Healthcare Home Nurse Care Manager provides education, support, connection to services and wellness coaching to individuals with chronic health conditions and behavioral health or substance use disorders.  The Nurse Care Manager is an active member of the care team for individuals on their caseload.   

ESSENTIAL DUTIES AND RESPONSIBILITIES

The essential functions include, but are not limited to the following:

• Provides education and connection to services to consumers with chronic physical health conditions or may be at high risk for developing health conditions, such as diabetes, COPD, obesity, heart disease, etc. 
• Champions healthy lifestyle principles while educating clients and families utilizing evidenced-based practices and interventions which support healthy lifestyle practices and goals.
• Assists consumers in accessing and addressing their primary and specialty care needs. 
• Uses health information tools (MyAvatar, CareManager, Cyber Access, KHIN, CIMOR and other designated systems – training provided) and Excel for management of consumer needs and position expectations.
• Coordination of Metabolic Syndrome Screenings for persons identified meeting defined criteria.
• Performs point of care metabolic screening testing via Cholestech LDX and Afinion Hgb A1c analyzers – training provided. 
• Coordination with community support, peer support and other teams for a holistic approach to consumer care.
• Participates in Integrated Care Team Meetings. Provides education at the monthly team meetings for the community support worker groups.
• Provides education at monthly team meetings for community support worker groups. 
• Coordinates care with pharmacies and providers in the community and with Tri-County Mental Health Services or other safety net providers to promote improved health outcomes. 
• Develops and updates patient-centered treatment plans in coordination with annual Healthcare Home health screenings and follow-up appointments. 
• Other duties as assigned. 

MINIMUM QUALIFICATIONS (KNOWLEDGE, SKILLS, AND ABILITIES)

Education/Certifications:

• Registered Nurse certification required
• CPR/First Aid certification required
• Annual TB testing required
• Active driver’s license and minimum state-required insurance

Experience Required:

• 1-2 years of similar position-related 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 Word and Outlook.  
• Experience with electronic medical records.  
• Proficiency with point-of-care metabolic screening testing and vital sign collection used for metabolic syndrome screenings.  
• Excellent patient/consumer education skills.  Excellent organization and prioritization skills. 
• Motivational interviewing experience preferred.