Re-Entry RN Care Manager

Primary Health Solutions•Hamilton, OH

23h•Hybrid

About The Position

The Re-Entry RN Care Manager serves in a dual-role supporting jail re-entry coordination for justice-involved patients and integrated care with a partner behavioral health practice. This role is responsible for facilitating safe, timely transitions of care, reducing gaps in medical and behavioral health services, and improving health outcomes for high-risk populations through comprehensive nursing care management, care coordination, patient education, and interdisciplinary collaboration.

Requirements

Graduate of an accredited School of Nursing.
Current, unrestricted Registered Nurse license in the state of Ohio.
Minimum of 3 years of nursing experience.
A minimum of 2 years of care management experience is required, preferably in a healthcare or social services setting.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
Ability to write routine reports and correspondence.
Ability to speak effectively before groups of customers or employees of organization.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Ability to gain knowledge of current practice management system, electronic medical record, Microsoft Word, text paging, Internet, and Intranet.

Nice To Haves

Experience working with individuals transitioning from the criminal justice system (e.g., jail or prison) or experience in behavioral health or substance use treatment strongly preferred.

Responsibilities

Facilitate care coordination for patients transitioning from jail or other community institutions, ensuring they are linked to primary care services immediately upon release.
Complete intake assessments for individuals leaving jail to identify their medical, mental health, and social needs.
Formulate and implement a care management plan that addresses the patients identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; educating the patient/family on the choices available. Establishes a care management plan that is mutually agreed upon by the health care team and the patient/family. Plans will contain specific self-management goals, objectives, and interventions with the patients that are action oriented. Identifies barriers and empowers patients/families to achieve maximum levels of wellness and self-management. Involves patient/family in the formation and ongoing evaluation of the plan of care.
Evaluate the effectiveness of the plan in meeting established care goals; revise the plan as needed to reflect changing needs, barriers/ issues and goals. Monitor and evaluate the progress of the patient.
Schedule and coordinate appointments for patients needing medical care, mental health services and other specialty care.
Provide benefit coordination including assistance in enrolling into state and federal benefits e.g., Medicaid.
Complete accurate medication reconciliation identifying any discrepancies and collaborating with providers to resolve medications- related issues.
Administer vaccines ensuring proper documentation, patient education and adherence to safety and regulatory requirements.
Maintain accurate documentation of all interactions, care plans, and patient progress in the patient tracking system.
Work with correctional facilities, probation officers, and other community organizations to ensure seamless service coordination and care delivery.
Drive improvement of clinical quality measures in partnership with the rest of the quality department.
Perform and/or participate in other appropriate projects or duties as assigned this may include vaccine clinics, home visits or other off site nursing needs.