The Nurse Care Coordinator shall provide regional primary care consultation, psychiatric care consultation; work with the Behavioral Health Home Organization (BHHO) & Certified Community Behavioral Health Clinic (CCBHC) team, Child Assertive Community Treatment Team, Private Non-Medical Institute, and other members to facilitate care across the healthcare continuum.
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Provide education and support around medications to the Interdisciplinary Team (IDT), members, and families.
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Provide medical education about chronic disease management to IDT members, families and groups.
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Liaison to Health Home, ACT Teams, CCBHC Practices/Primary Care Physicians.
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Collaborate with the IDT on member plan of care.
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Review Health Questionnaire and provide recommendations to IDT and/or members and families for medically compromised participants.
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Assist, and/or make recommendations regarding skill development in activities of daily living, including hygiene, nutrition, exercise, general health maintenance/improvement.
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Support implementation of grant funded projects such as In-Shape, CTI, and other health and wellness pay for performance initiatives in geographical area where program is offered.
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Support Behavioral Health Home team, CCBHC and Child ACT in achieving organizational and state required outcomes, including but not limited to A1C testing, tobacco screening and annual health screenings.
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Be proficient in EHR, HIN, and VMS systems in order to extract clinical data and alerts in order to support level of care.
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Consult with IDT and members as indicated regarding discharge planning recommendations and follow up.
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Monitor emergency department usage and coordinate with IDT and other providers to promote least restrictive level of care.
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Medication reconciliation through EHR from external providers (i.e. PCP, Specialists, etc.) when appropriate.
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Provide medication and medical education to Interdisciplinary Team (IDT), members, and families.
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Complete pharmacy enrollments, medical equipment orders, and other supports/services to support recovery goals.
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Provide CRMA Training and Supervision as needed.
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Schedules will vary according to program needs (as applicable):
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On-call responsibilities as assigned
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Provide excellent customer service
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Active participation in supervision of student interns, as appropriate and needed.
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Ensure the confidentiality of all patient information and release of information from area(s) of responsibility.
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Ability to support and recognize the important role volunteers play. Sweetser employees work with, support, collaborate with volunteers, and promote opportunities for volunteer engagement
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Exercise judgment consistent with clinically accepted standards of community practice in determining whether to transport a particular patient(s).
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Maintain adequate personal vehicle insurance coverage, a valid state driver’s license, a vehicle that is in good repair and a good driving record as per organization policy.
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Active participation in required supervision as determined with Program Manager according to licensure level.
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Timely and accurate provision of administrative paperwork according to the time frame established by the organization’s policies.
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Active participation in administrative meetings, including program meetings and general staff meetings.
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Understand and comply with all Sweetser policies and procedures as identified in the Human Resources Policy Manual.
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Maintain administrative responsibility (charting/documentation, etc.)
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Active participation in in-service training and continuing education programs.
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Active participation in providing community education to staff, community groups, etc., as appropriate and needed.
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Maintain minimum number of training hours mandated by professional licensure and required by state licensing.
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Maintain relationships with patients that promote dignity, equality and self-determination.
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Provide productive and supportive collaboration with peers/colleagues in the same program and across programs.
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Maintain productive and efficient relationships with all organization-wide personnel and programs.
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Maintain positive representation of the organization, at all times, with the public.
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Follow Suicide safer care practices.
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Other duties as assigned.