RN Case Manager

Sstar; Fall River (MA); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Paid time off

401(k)

Disability insurance

Employee assistance program

Vision insurance

Pet Insurance

Job summary

SSTAR is seeking an Entry Level Nurse Case Manager to assess, triage, and plan care for patients entering MAT services. The role collaborates with the MAT Team to enroll patients into MAT, primary care, and behavioral health services, while following clinical and policy guidelines.

Responsibilities include intake, coordinating with care teams, providing direct patient care, documenting thoroughly, and supporting patients through treatment progression in a federally qualified health center

Qualifications

• Active RN license in Massachusetts.
• Current CPR certification is required.
• Experience with substance use disorder care and OBAT programs preferred.
• Ability to lead and coordinate care across teams.
• Strong communication with patients, families and providers.
• Knowledge of MAT/MOUD delivery and policies.

Responsibilities

• Conduct initial assessment and intake including medical and social history.
• Coordinate with MAT team for enrollment and ongoing care.
• Provide direct patient care for OBAT patients and counseling.
• Monitor treatment progress and medication adherence.
• Maintain accurate documentation and patient records.

Skills

RN License

CPR Certification

SUD care

Team Leadership

Care coordination

MOUD knowledge

Communication skills

Cultural sensitivity

Clinical assessment

Job description

• Job Level:Entry Level (less than 2 years)

We’re more than just quality treatment for substance use disorders.We’re a total health community. At SSTAR, our mission is healing thecommunity, one person at a time. We will provide a personal level ofhealthcare and addiction treatment that addresses the mental,physical, and spiritual well-being of everyone we touch. SSTARis a Federally Qualified Health Center (FQHC) which affords ouremployees eligibility to apply for one of our three Loan Repayment Programs.

The Nurse Case Manager is responsible andaccountable for assessing, triage and developing a plan of care forpatients whom, walk in, call in or are referred to the MAT Program atSSTAR. The Nurse Case Manager is responsible forworking in collaboration with the MAT Team to assist patients withenrollment into MAT Services, primary care, inpatient, behavioralhealth, recovery coach services etc.

Responsibilities:

• Conduct initial assessment and intake obtaining social, medical,mental health, substance abuse and medication history
• Review Policy and procedures for Injectable medications update as needed
• Assign appropriate tasks to staff consistent with their job duties
• Coordinate with managed care case manager and LPN delivery ofmedications/stop delivery of medication
• Monitor medications that are on site for duplicate deliveries ordelivers for patients that have been lost to care
• Attend Next Gen Round Up meetings report any issues r/t Next Gen usage/performance/problems
• Report Next Gen Round Up solutions/trainings/updates
• Facilitate meetings/staff trainings related to Next Gen upgrades/updates/workflow
• Provides direct patient care to patients with opioid and substanceuse disorders, screening, and telephone triage, performing intakes,supervising initial buprenorphine induction, and providingcounseling on therapies for substance use disorder
• Responsible for improving the care of our patient populationacross health, substance use and mental health treatment, promotingpatient activation and empowerment for shared decision-making intreatment, and encouraging healthy behaviors, self-management ofhealth, mental health and substance use conditions
• Monitor the health status, treatment progress, and medicationadherence of the OBAT patient panel
• Schedule follow up appointments/ Intakes/Inductions with nursecase managers /schedule intakes /follow ups with MAT provider/schedule follow up appointments /physicals with primary care providers
• Revise the patient plan of care with the OBAT treatment team, asneeded, to address patient needs and issues
• Directly support our medical specialty providers and behavioralhealth specialists during clinical sessions
• Communicates and collaborates with care team providers includingPCP, specialists, behavioral health providers, psychiatric nursepractitioner, caseworker and other team members as deemed appropriate
• Full Time Nurse Case Manager to carry a case load of 100-125patients Provide follow up care in person and via telephone when needed
• Nurse Case Managers work Autonomously, following the Nurse DrivenModel for all OBAT sites across Massachusetts.
• Review consents and treatment contracts with patients, obtainingsignatures and giving the patient a copy and leaving a hard copy inthe patient paper chart
• Facilitates and track referrals and serves as the central contactfor patients and their families, BH providers, specialists whenneeded. Collaborate as needed with physicians, social worker, andspecialty care physicians to whom the patient has been referred.
• Manage patients receiving opioid treatment medications on anongoing basis
• Assessment of signs and symptoms of opioid withdrawal using theClinical Opioid Withdrawal scale/CIWA Scale
• Monitoring of patients in the induction, stabilization, andmaintenance phases of treatment
• Assess patients looking to access both behavioral health, and OBATservices at SSTAR Family Health Center
• Follow State and Federal guidelines in providing care toopioid-dependent patients
• Complete appropriate documentation with excellent record keepingincluding visit notes. Use clear concise and effective communicationwritten/oral and comply with departmental policies whensharing/documenting relevant patient care data
• Collect pertinent data using appropriate assessment techniquesi.e., OBAT intake and enrollment paperwork as well as quarterly OBATquestioner and OBAT Dis-enrollment paperwork. Submit to supportstaff for data to be entered into virtual gateway.
• Evaluate data according to the patient’s immediate conditions andneeds, review hospital records with MAT provider and/or PCP.
• Involve the patient, and appropriate health care providers in thecollection of data when appropriate
• Ongoing education and support of patients in all phases ofsubstance use treatment including nursing visits scheduled andunscheduled (walk -in), urine toxicology screens, routine labs andas needed, medication teaching, monitoring, medication counts,observed dosing, and medication refills
• Works with the specialty as well as retail pharmacies and the OBATteam in obtaining medication orders, prior authorizations,prescriptions, refills, and communication as needed
• Contact with outside agencies DCYF, Probation, Parole, Medical Providers.
• Obtain access to the Massachusetts Prescription Monitoring Programonline portal look-up/review patient data document findings, alertprovider if review has abnormal findings
• Collaborate and coordinate care with BH team members aroundpsychiatric emergencies or crisis-related clinical concerns
• Attend weekly OBAT Team meetings
• Commit to a focus on continuous improvement of workflow processesand procedures
• Assume other responsibilities, as directed
• Must cooperate fully with SSTAR’s Corporate Compliance Program andperforms all tasks as assigned by the Director and/or CEO

Experience and Skills:

• RN License to practice in Massachusetts
• Knowledge of Medication for addiction treatment
• Current CPR Certification
• Experience caring for patient with mental illness or SUD required
• Ability to diffuse tense situations related to patient care
• Leadership experience with the ability to work autonomously
• Knowledge of community, and health resources, particularlysubstance use-related resources and supports
• Ability to interact and communicate with a variety of people, bothon a one-on-one basis and in meetings and group presentations; mustbe able to relate to and work with ill, emotionally upset, andsometimes hostile people
• Ability to anticipate and react calmly to emergency situations
• Values cultural diversity and other individual differences in theworkforce, ensuring that the organization builds on these differences
• CARN CERTIFICATION (once eligible after 2000 hours of clinic)
• At least 2 years continuous sobriety is required for people inrecovery from drugs or alcohol
• 403B Retirement Plan
• Disability insurance provided through the state
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid vacation, illness and holidays
• Vision insurance
• Pet Insurance