Job Description

Natalis Outcomes is a leader in providing the finest Behavioral Home Health Services in Minnesota. Our caring, professional staff is our most important asset and the very heart and center of who we are. Each day we strive to ensure that your experience working at Natalis Outcomes reflects the importance of your role as we carry out our mission. To that end, we have established seven principles that we believe will make a positive difference at Natalis Outcomes and the world at large. As we grow, we are committed to upholding these principles without compromise, rating no principle more important than any other. These principles are paramount in your role as Integration Specialist. They are the first seven job qualifications listed below.

PRINCIPLES:

• Treat everyone with respect and dignity.
• Embrace diversity as an essential component of our culture.
• Create an environment filled with fun, laughter, and good humor.
• Understand that our clients are our customers and are entitled to exceptional service all of the time.
• Be humble enough to invest in a client’s dream rather than the dream we may have for them.
• Acknowledge our gifts by doing one extraordinary thing each day to make the world a better place.
• Recognize that profitability is essential to our success.

QUALIFICATIONS:

• Minnesota licensed Registered Nurse (RN).
• Associate Degree in Nursing – Bachelor of Science Degree preferred.
• Chronic Disease or Case Management Certification preferred.
• 3+ years of medical and/or mental health nursing experience.
• Experience working with medical case management or medical care coordination preferred.
• Understanding of mental health diagnoses and treatment modalities.
• Excellent written and verbal communication skills.
• Excellent organizational skills.
• Ability to work independently and effectively balance multiple tasks, timelines, etc.
• Ability to manage and supervise other nursing staff.
• Maintain a valid driver’s license, obtain company insurance approval, and have use of a viable and safe vehicle during work hours.

I. GENERAL

PRIMARY FUNCTIONS

SPECIFIC ACTIVITIES UNDERTAKEN TO ACHIEVE THE FUNCTION

Overall Health and Wellness Case Management and Care Coordination

A. Supervise other nursing staff as may be required

B. Conduct all Health and Wellness Assessments.

C. Provide direct health and wellness coaching to clients as needed.

D. Serve as point of contact for BHH team regarding all client health needs and concerns.

E. Aid in review and revision of client Health Action Plans every six months.

F. Review client prescriptions and medications.

G. Answer client questions/concerns regarding medical issues, appointment, prescription medication side effects, drug interactions, and contraindications.

H. Coordinate medical referrals.

I. Assist with discharge and transitional care planning from short or intermediate length institutional care settings.

J. Work with Psychological/Psychiatric providers as needed.

K. Maintain appropriate licensing as required for BHH Integration Specialist.

II. CLIENT CENTERED SERVICES – MEDICAL & DENTAL

PRIMARY FUNCTIONS

SPECIFIC ACTIVITIES UNDERTAKEN TO ACHIEVE THE FUNCTION

Utilization of other BHH team members in ensuring health and wellness goals are achieved.

A. Conduct Health and Wellness Assessment on all new BHH clients within 14 days after Brief Needs Assessment has been completed.

B. Conduct bi-annual Health and Wellness Assessments on every client.

C. Communicate results of assessments with BHH team members.

D. Provide direct health and wellness coaching to clients as needed.

E. Discuss health assessment with client and /or refer clients to community health programs and resources for managing chronic conditions of all types.

F. Obtain and coordinate medical referrals.

G. Review clients’ prescribed medication list.

H. Coordinate prescription drug change information sharing.

I. Answer questions/concerns about drug interactions, contraindications, and side-effects.

J. Serve as point of contact regarding all client health needs and concerns with primary care and other specialty medical clinics.

K. Work with Case Manager to co-manage chronic and/or serious health needs.

L. Take lead and oversee required preventative screenings, track proof of screenings done through the patient registry, and follow up with BHH team members accordingly.

M. Follow up with client to determine willingness to follow medical recommendations.

N. Follow up with Case Manager to review client medical/dental visit summaries.

O. Assist with discharge and transitional care planning from short or intermediate length institutional care settings.

P. Be aware of all client hospitalizations.

III. CLIENT CENTERED SERVICES – PSYCHIATRIC/PSYCHOLOGICAL

PRIMARY FUNCTIONS

SPECIFIC ACTIVITIES UNDERTAKEN TO ACHIEVE THE FUNCTION

Utilization of other BHH team members in ensuring psychiatric/ psychological goals are achieved.

A. Work with psychiatrist/psychologist as needed for medically related treatment issues, recommendations, and referrals.

B. Be aware of all client psychiatric hospitalizations.

IV. DOCUMENTATION

PRIMARY FUNCTIONS

SPECIFIC ACTIVITIES UNDERTAKEN TO ACHIEVE THE FUNCTION

Ensure that all client related documentation is complete and up to date.

A. Recognize the critical nature of recording accurate and efficient case notes to memorialize case management and coordination.

B. Recognize the critical nature of recording accurate case management notes to track client progress.

C. Recognize the critical nature of case management notes as a means of communicating information to the team.

D. Record all case notes immediately after meeting with client but in no event later than end of day seen.

V. TRAINING FOLLOW-UP

PRIMARY FUNCTIONS

SPECIFIC ACTIVITIES UNDERTAKEN TO ACHIEVE THE FUNCTION

Ensure compliance with training licensing regulations and company policies and procedures.

A. Meet training requirements by attending all in services and training classes within training timelines.

B. Attend and actively participate in staff meetings.

C. Other areas, as may be determined.

VI. OTHER

PRIMARY FUNCTIONS

SPECIFIC ACTIVITIES UNDERTAKEN TO ACHIEVE THE FUNCTION

Promote Natalis Outcomes in a positive manner to our partners, the community, and outside agencies.

A. Maintain a working knowledge of medical, psychological, financial, social, housing, transportation, education, and job training resources.

B. Provide effective oral and written communication between Natalis Outcomes, partner agencies, and other community service organizations.

C. Promote positive public relations between Natalis Outcomes, partner and outside agencies, and the community at large.

D. Adhere to all Natalis Outcomes’ policies, procedures, and principles.

E. Other areas, as may be determined.