Behavioral Health Homes Registered Nurse

MN Adult and Teen Challenge•Minneapolis, MN

81d•$67,000 - $75,000

About The Position

The Systems Navigator (Behavioral Health Homes Registered Nurse) leads assessment and planning for Behavioral Health Home Services. The role meets with members as needed to assess needs, review progress, make and assist with referrals, and provide health and wellness education, direct support, and advocacy for individuals served. The nurse conducts intake and health and wellness assessments, develops and updates person-centered Health Action Plans, coordinates care and referrals, and helps members access health care, behavioral health, social services, vocational supports, and other appointments. The role collaborates regularly with Integration Specialists and Qualified Health Home Specialists, supports recovery and health goals, maintains complete records, and reports incidents and potential maltreatment. The position also involves ongoing career and competency development.

Requirements

Current Minnesota Registered Nurse (RN) license in good standing.
At least three years of clinical nursing experience in behavioral health, community health, home care, case management, care coordination, or population health.
Experience conducting comprehensive assessments, developing person-centered care plans, and coordinating services across health care and community systems.
Knowledge of community resources, health care systems, benefits, housing supports, and care coordination.
Ability to perform care planning, coordinate services, monitor goals, and support client engagement.
Comfort and compassion in working with individuals facing mental health issues, addiction, and other life-controlling challenges.
Demonstrate MnTC's mission, Culture of Honor, core values, and Putting Honor in Action principles in daily interactions.
At least one year of freedom from problematic substances.
Pass a DHS background study as required under Minnesota Statutes, Chapters 245C and 245G.
Able to sit at a desk and work on a computer for prolonged periods, stand, bend, and reach for prolonged periods, and lift up to 25 pounds at times.

Nice To Haves

Knowledge of Behavioral Health Home (BHH) requirements, social determinants of health, and community resources.

Responsibilities

Conduct an intake interview and brief needs assessment for each referred person.
Ensure enrolled members receive information about the purpose of BHH services and their rights and responsibilities.
Coach members and their identified supports regarding BHH services.
Notify the Managed Care Organization of a member's enrollment in BHH services when appropriate, using the Department of Human Services form.
Coordinate a meeting for each referred person with the Integration Specialist.
Meet with clients, gather information, and complete Health and Wellness Assessments.
Develop measurable goals and objectives for Health Action Plans using person-centered interviews and assessment information; submit plans to the Integration Specialist for review and approval and obtain the individual's signature.
Update Health Action Plans at least every six months or more often when needs or goals change significantly.
Conduct regular progress reviews of Health Action Plans as required by BHH policy and procedure, and update plans every six months for continuing-service members.
Attend monthly or more frequent meetings with the Integration Specialist and Qualified Health Home Specialists to consult, collaborate, and identify priority cases.
Help individuals prepare for and attend health care, behavioral health, social services, vocational support, and other appointments; identify access barriers and arrange supports such as transportation, accompaniment, advocacy, or self-advocacy instruction.
Develop competency in providing member Health and Wellness Education using resources approved by the Integration Specialist.
Develop and demonstrate Motivational Interviewing skills to help individuals address ambivalence or resistance to health and wellness goals.
Refer people to resources appropriate to screening results, understand substance use disorder referral processes, ensure follow-through, and integrate substance use disorder treatment plans into comprehensive care planning.
Assess individuals' readiness for change and capacity to integrate health care or community supports into their lives.
Build productive partnerships with health care and social service providers through proactive communication and education about BHH services.
Facilitate collaboration when individuals receive other agency services, and offer, schedule, and facilitate individual Recovery Team Meetings in conjunction with Health Action Plan or Treatment Plan development and updates.
Manage time to meet assessment and planning requirements and maintain accurate, complete service and health care records.
Report incidents, potential maltreatment, and sentinel events to the Integration Specialist within 24 hours.
Meet weekly with Qualified Health Home Specialist partners to review the prior week and upcoming needs; review contact records to confirm members or their primary care providers had contact within the last 30 days and identified needs were met.
Participate in ongoing career development and work toward career and competency improvement goals.