Nurse Care Manager

Under the direction of the Supervisor of Integrated Health Services, the Nurse Care Manager provides culturally competent and trauma informed services to all consumers, assists consumers to design and implement strategies for obtaining services and supports that are goal-oriented and individualized. A Nurse Care Manager is responsible for assessment, planning, linkage, advocacy, and coordination developed through the person-centered planning process. The Nurse Care Manager will coordinate and manage all aspects of a consumers care, including providing comprehensive intersystem and interdepartmental collaboration to ensure the needs of consumers are met timely and appropriately. The Nurse Care Manager supports the delivery of the LifeWays Substance Use Disorder Health Home model services. The Nurse Care Manager incorporates LifeWays mission, vision, and values into all decision-making processes.

Essential Functions

1. Welcomes all individuals by demonstrating empathy and providing opportunity for the person presenting to describe their situation, problems and functioning difficulties, exhibiting excellent customer service skills, and working with them in a non-judgmental way.

2. Collects information from individuals for decision-making and reporting purposes.

3. Coordinates all referrals from provider network to Outpatient Psychiatry program. Monitors Outpatient Psychiatry caseload and completes updated assessments, preplans and treatment plans as needed to continue appropriateness of continued services.

4. Coordination of care within and outside of the provider network when referring for additional services due to Level of Care need changes and / or when coordinating whole health services for consumers.

5. Coordination between psychiatrists, primary care physicians, dentists, other healthcare specialists, and other community providers when necessary to discharge from services to ensure appropriate after care planning and follow-up.

6. Provides services to individuals through in person, telehealth, and telephonic communications with the patient, physician, psychiatrist, other health care providers, and others.

7. Assures that the plan of service identifies what services and supports will be provided, who will provide them, and how the services and supports will be monitored under each goal and objective (i.e., interval of face-to-face contacts).

8. Performs transition planning services and assessment / reassessment as permitted and upon due date.

9. Ensures accurate medical necessity screening and submission for Psychiatry Review.

10. Ensures implementation or oversight of the transition plan.

11. Oversees implementation of the individual plan of service, including supporting the consumers dreams, goals, and desires for optimizing independence; promoting recovery; and assisting in the development and maintenance of natural supports. Utilizes their knowledge to discuss the current treatment plan with the psychiatrist and discuss alternate treatment plans.

12. Assures the participation of the consumer on an ongoing basis in discussions of his plans, goals, and status.

13. Coordinates the consumers services and supports all providers, making referrals, and advocates for the consumer.

14. Facilitates the transition (e.g., from inpatient to community services, school to work, dependent to independent living) process, including arrangements for follow-up services.

15. Assures the patient is in the appropriate status and level of care based on Medical Necessity.

16. Assists consumers with crisis planning.

17. Identifies the process for after-hours contact.

18. Performs care management functions for LifeWays Substance Use Disorder Health Home (SUDHH).