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Job Summary Under limited supervision, uses intermediate skills obtained through experience and training to improve the physical health status of clients with serious mental illness, including those with co-occurring substance use disorders, who have or are at risk for comorbid primary care conditions and chronic disease. Conduct assessments, draft client care plans, make changes to treatments in care plans. Manages transitions of care with hospital discharge planners. Coordinates care of all clients still in Treat-to-Target stage or high disease acuities. Supervises a team of care workers and wellness coaches and utilizes an Electronic Health Record system to ensure that there is no break in the care provided.
Responsibilities Conduct social and medical risk assessments on clients including monitoring patient vital signs and develop plans of care specific to their health needs. Assessments may be conducted on ACCESS property or in clients homes
Enroll clients into appropriate program benefits and activities and monitor progress. Coordinate the delivery of benefits and services to clients. Refer clients to other services as needed
Advocate on behalf of client in written and oral form when providing necessary referrals and contacts with other departments/agencies/companies
Assist clients in recognizing and understanding “at risk” behaviors.
Provide one to one health education to clients
Plan, provide and/or conduct educational presentations to clients
Functions as a member of a multidisciplinary team that includes a nurse practitioner and clinicians
Review, interpret and explain to program participants the policies and procedures of the program
Document all services in compliance with the agencies quality assurance plan. Report on program progress at required intervals per funding guidelines
Develop and update educational materials for use by patients. Participates in team reviews, staff meetings and staff trainings
Maintain agency confidentiality, client’s privacy, and HIPAA compliance
Supervise, coach, and assess staff performance
May participate in grant proposal writing and submission
May participate in audits as needed
Maintains currency on new developments in the nursing field as mandated by the National Council of State Boards of Nursing
Operates standard office equipment and uses required software applications.
Shall follow the funding sources requirements and CARF standards applicable to the services you provide
Performs other duties and responsibilities as assigned
Knowledge, Skills, and Abilities Knowledge of:
Guidelines and standards of the program
Medical/ health and social risk standards
Fundamental knowledge of concepts, practices and procedures used in nursing education and counseling as well as public health and dealing with high risk populations
Basic knowledge of training design and culturally sensitive delivery for individuals and groups
Skill in:
Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems
Instructing — Teaching others how to do something
Operating standard office equipments and using required software applications, including Microsoft Office, Excel and PowerPoint, the reporting software recommended by funding agency and the ACCESS Electronic Health Record system
Ability to:
Actively listen to clients
Partner with other functional areas to accomplish objectives
Facilitate meetings, ensuring that all viewpoints, ideas, and problems are addressed.
Organize and prioritize multiple tasks and meet deadlines
Communicate effectively, both orally and in writing
Speak and write in English. Ability to interpret, speak and write in Arabic, Spanish or other native language of the predominant service population a plus
Maintain confidentiality of agency and client information
Work independently as well as collaboratively within a team environment
Handle stressful situations and provide a high level of customer service in a calm and professional manner
Establish and maintain effective working relationships
Educational/Experience Requirements Minimum Degree Required:
Associate’s Degree in Nursing Bachelor’s Degree in Nursing preferred
~and~
Minimum of two years experience in supervising a team in a community health setting or other related health field or any equivalent combination of experience, education, and/or training approved by Human Resources.
Licenses/Certifications Licenses/Certifications Required at Date of Hire: Must be registered nurse in good standing based on current licensure requirements administered by the Michigan Board of Nursing Department of Licensing and Regulatory Affairs.
Working Conditions Hours: Normal business hours. Some additional hours may be required.
Travel Required: Local travel may be required.
Travel required within Wayne, Oakland, and Macomb Counties. Travel throughout the state may be required based on the assigned functional area.
Working Environment: Climate controlled office environment during normal business hours.