Job Description

• Perform initial health monitoring assessments and develop wellness care plan for ongoing monitoring visits not excluding performing diagnostics such as lab draw and/or administering injections while counseling education as well as provide any care coordination for referrals and prescriptions as needed
• Engaged closely with psychotherapists and scheduling staff to ensure admissions are scheduled for initial health monitoring visits
•  Enroll clients into wellness program and national outcomes measurement system as applicable
•  Daily review of diagnostic results including laboratory studies for critical values and address appropriately
•  Work with the CASES employees on the PCBHI team and work closely in collaboration with the IFH provider (FNP/MD) to provide clinical updates around the team's integration into the Nathaniel Clinic's operations and services for consumers receiving outpatient services
•  Participate in organizational, weekly multidisciplinary meetings and case conferences with all providers (MH, primary care, pharmacy, care managers, housing providers, and criminal justice providers) serving consumers for joint treatment planning, shared decision-making, and complex care review
•  May provide psychotherapy, initial comprehensive assessments, and complex care management to a small caseload of PCBHI consumers
•  Ensure evidence-based practices, Wellness Self-Management Plus, smoking cessation and weight loss services are effectively implemented.
•  Maintain all quality, compliance, utilization review and regulatory controls to ensure appropriate and high-quality services, in consultation with Nathaniel Clinic Director, IFH leadership and providers, consumer representatives, advisory group, Evaluator, Managed Care Organizations and Health Homes.
• Review clients records for annual physical review and health monitoring progress as well as ensure the quality and timeliness of clinical documentation in accordance with CASES and IFH standards
• Collaborate with external evaluator and ensure integrity and quality of program data
• Routinely use data including PSYCKES quality health indicators, Managed Care Organization (MCO) data, and program level data to monitor, track, and analyze the effectiveness and cost of services.
•  Ensure PCBHI consumers are engaged in Health Home care management.
•  Assist team members through individual and group conferences in analyzing case problems, improving services and consumer outcomes.
•  Ensure appropriate team follow-up and discharge coordination following consumer ER visits and inpatient stays.
•  Recommend policies and procedures to promote integrated care within the Nathaniel Clinic and for ACT consumers.
•  Interface with IFH leadership, and CASES' quality assurance, corporate compliance, EHR, strategic planning & analysis, fiscal/business staff to ensure services are effectively implemented and are sustained.
•  Support PCBHI sustainability activities with active participation in evaluation, outreach, engagement, and presentations to MCOs, Delivery System Reform Incentive Program (DSRIP) Performing Provider Systems, NYS and NYC mental health and health agencies, and Health Homes.
•  Provide 24-hour emergency and crisis intervention rotating phone coverage.
•  Order medical supplies as needed and perform monthly exam room checks.
•  Provide culturally competent services in accordance with CASES policies.
•  Any other duties as required by supervisory and directors.

Qualifications

•  Registered Nurse (RN) in NYS
•  At least one year experience working with adults with serious mental illness and co-occurring substance use disorders
•  Proficient in behavioral health and primary care integration models
•  Ability to work effectively with diverse team and remain highly organized
•  Proficient in computers and Electronic Health Record (EHR)
•  Fluency in Spanish preferred

Additional Information

Only applicants selected for interviews will be contacted.

CASES is proud to be an Equal Opportunity Employer. Employment with CASES is based solely on qualifications and competence for a particular position, without regard to race, color, ethnicity or national origin, age, religion, creed, gender, sexual orientation, disability, or marital, military, or citizenship status. We also actively recruit individuals with prior involvement in the criminal justice system.Your information will be kept confidential according to EEO guidelines.