rn care coordinator - Fort Worth, TX , USA, United States - MHMR of Tarrant County

Description

Pay is determined by relevant experience, work history, education and internal equities. As part of our Diversity, Equity, and Inclusion practices, MHMR offers the maximum compensation for candidates based on their experience, education and internal equities of the agency. This practice removes biases in compensation and assist hires and/or promotions on pay equity in their appropriate position(s) at MHMR.

The average rate for this position is

I) Job Purpose

The Registered Nurse (RN) utilizes nursing judgement and critical thinking skills using a collaborative process to implement care coordination to advocate, facilitate and improve the health outcomes of our consumers. The Registered nurse will review records to determine appropriate care, assist with transition of needs, ensure appropriate quality and quantity of services are provided, collaborate with treatment team and provide core team with education materials and training. The RN will assess patient data to look for potential gaps in care as well as tracking and trending lab work, and hospital and Emergency department utilization. The RN will utilize a disease management focus to guide the care coordination team.

II) Essential Functions

A. Manage Risk Stratification for Care Coordination.

Performance Standards

• The RN will oversee systems for identifying high, medium and low risk consumers through the electronic health record, referrals, registries or from MCOs.
• The RN will review consumers data to identify potential gaps in care and assign appropriate case management to coordinate care.
• The RN will provide ongoing evaluation of data and review documentation of the consumers progress to ensure consumer receives appropriate level of care.
• The RN identifies, develops and executes appropriate disease management activities and interventions such as, but not limited to consumers and/or group consumer contacts and training classes.

B. Provides nursing assessment and nursing interventions. These are based on use of the nursing process for planning and identifying current or predicted health care needs for individuals in services at the MHMR Tarrant location served or in the community.

Performance Standards

• The RN uses holistic care with the understanding individuals served at MHMR Tarrant have both behavioral health and physical health needs considered.
• The RN may use a comprehensive nursing assessment, a psychiatric nursing assessment or substance use disorder assessment to determine the behavioral health care needs of the individual and document in the medical record.
• The RN assesses vital signs, reviews medication management and health conditions, to determine safe care of the individual served.
• The RN provides psychiatric rehabilitation and education to the individual based on their needs.
• The RN participates in the development of treatment plans for individuals needing behavioral health services, to include the formulation of short and long term goals, evaluation, and treatment plan modification for each person.
• The RN make medication decisions for the individuals served in the program related to medication delegation, self-administration of medication or self-administration of medication with supervision.
• The RN provides oversight to unlicensed staff in medication competency to assist with self-administration of medication with supervision.
• The RN may act as nursing supervisor at the behavioral health location, assigning for care to individuals to LVNs and other staff, reviewing notes and assessments and nursing care of the individuals at the site.

C. Provides nursing care to each individual assigned or seen at the program and assures that necessary documentation regarding contact is contained in the clinical record by the end of the shift or day.

Performance Standards

• The RN documents all contacts related to individuals served in the program. These contacts may be by phone or face-to-face. These contacts may be related to care coordination inside the program or with outside providers, such as a pharmacy or physician or hospital.
• The RN completes a nursing progress note for each contact which is done with the individual. All nursing progress notes conform to MHMR Tarrant standards as well as Medicaid standards.
• The RN acts according to the Nurse Practice Act for all written and verbal medical orders. This includes all verbal orders received from the prescribers are documented as soon as they are received.

D. Provide nursing interventions to individuals in MHMR Tarrant Services.

Performance Standards

• Promote understanding and self-management of health issues.
• Medication Reconciliation and management
• Give and record injections according to medical orders and agency guidelines after each occurrence.
• Checks and records blood pressure of all identified hypertensive individuals and Clozaril patients at each appointment, and according to MHMR Tarrant Vital Signs parameters.
• The RN performs and records an AIMS Examination Procedure on each individual exhibiting symptom suggestive of first time Tardive Dyskinesia.
• Shows evidence of health and/or medication teaching related to the Treatment Plan in the notes. Evaluates needs/outcomes of those receiving the instruction and documents each occurrence.
• Assumes accountability when using independent clinical judgement and established protocols. Exercises the option of team consensus gathering when faced with decisions that involve other disciplines or complex clinical issues.

E. Works jointly with the prescribers to assure protocols are being followed 100% of the time.

Performance Standards

• Assist the prescriber to ensure compliance with lab studies, EKGs and the procedures regarding the standard of practice for lab and EKG reviews.
• Provides care coordination to ensure continuity of care relating to behavioral health and physical health conditions. This includes follow ups after emergency department visits and hospitalizations, as well as follow ups with primary care providers.
• Always promote collegiality among health care team members, through collaborative communication.
• Maintain medications for the behavioral health site. Ensure medication inventory for all medications on site is completed and documented according to protocol.

F. Works with other Health Care providers to ensure adequate medical care for individuals served.

Performance Standards

• The RN collaborates with other health care providers and members of the organization to solve clinical care problems each time they occur.
• The RN maintains necessary supplies for implementation of agency policies and procedures on infection control, according to the Infection Control Manual.
• The RN maintains medical supplies at site for medications and procedures.
• The RN carries out measures to prevent exposure to and transmission of pathogens in accordance with agency standards on infection control.
• The RN participates in identification and monitoring of measurable quality care outcomes.

G. Assists in provision of optimum physical and psychological environment for all individuals at the program site.

Performance Standards

• The RN responds promptly in medical and program emergency situations by carrying out appropriate interventions per unit protocol, as evidenced by successful completion of procedure, reporting of incidents to clinical supervisors and required administrative staff and completion of documentation.
• The RN, in collaboration with other program site team members, anticipates and interprets an individual's behavior to prevent crisis situations based on individual needs to assure the safety of the program site.
• The RN assists other program site team members in maintenance of a safe, secure, and orderly program unit environment.

H. Meetings, Committees & other information.

Performance Standards

• Participates on organizational-wide and nursing committees while balancing responsibilities at this service site as schedule permits.
• Communicates with clinical supervisor regarding complex clinical or ethical issues, each time they arise.
• Actively promotes wellness oriented lifestyle behaviors for those individuals served as evidenced by nursing progress notes.
• Carries out measures to prevent exposure to and transmission of pathogens in accordance with agency standards on infection control at all times.
• Participates in identification and monitoring of measurable quality care for those individuals served at this location.

I. Maintains a professional and ethical code of behavior.

Performance Standards

• The RN always maintains confidentiality of all individuals served, agency or prescriber related information within and outside the program setting.
• The RN contributes to the learning experience of new employees, students and other agency personnel.
• The RN maintains neat and professional appearance. RN will wear agency approved scrubs and badge at all times while on the clock.
• The RN addresses individuals served in the community and at the site, visitors and co-workers in a pleasant and respectful manner.

J. Shows evidence of continuing professional growth.

Performance Standards

• Nurse will complete all MHMR Tarrant agency training requirements within first 60 days of employment and will complete all annual training updates as required.
• In-services or continuing nursing education programs will be attended which benefit nurse's knowledge and client care. These must be approved by the supervisor. Will provide a copy of the attendance roster for verification.
• Nurse will maintain continuing nursing education units to comply with standards set by the Texas Board of Nursing, as evidenced by and proof of attendance.
• Evidence of all outside training as well as any upgrades in credentials will be forwarded to the Training Department and/or the employees Personnel File/Human Resources.
• Scheduled nursing meetings will be attended to facilitate networking, professional growth and information dissemination, as scheduled.

III) Knowledge of Laws, Regulations, Policies/Procedures, Skills, and Abilities

• MHMR Tarrant Policies and Procedures
• Texas Nurse Practice Act including RN scope of practice standards
• Texas Health and Human Services Mental Health Rules and Statutes
• Medicaid Standards
• The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
• International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10)
• ANA Code of Ethics for Nurses
• Ability to work cooperatively with multidisciplinary staff.
• Familiarity with chronic mental health, integrated health and chronic disease populations and optimal care trends.
• Knowledge of medications, their use and typical side effects.
• Ability to distinguish between medical and nursing interventions.
• Ability to advocate for the patient.
• Familiarity with trends in substance use disorder treatment .

IV) Internal & External Customer Service

• All participating pharmacies, Health Care Providers in the Community, Trinity Springs Pavilion, John Peter Smith Hospital, various private hospitals in the community, and public health clinics.

V) Travel

This position requires driving to and from locations for work and/and may require overnight traveling. Employees are required to have a license in good standing and be able to be covered by agency liability insurance. If personal vehicle is utilized for work travel, then maintaining personal auto insurance coverage is required.

Minimum Requirements

Required Education
Associates Degree

Defined Education
Nursing

Required Experience
Two (2) years

Defined Experience
Clinical Experience

Substitutions
None

Required License
Licensed RN in State of Texas
Valid Texas driver's license with an acceptable driving record.
Must provide license (if applicable) and official documentation of all educational attainment i.e. Transcript/Degree/Certificate

Required Supervisory Experience
0 year(s)

Testing Requirements
Pre-employment tests including drug and TB Screening, Physical Exam including balance and lift test.

Lifting Requirements
Up to 55 lbs

Our Benefits:

All staff are required to participate in agency Emergency Preparedness and Environmental Safety programs and may be assigned by their departments as a key/essential staff level function during critical events or for the purpose of sustaining business continuity.

This position may require temporary or permanent re-assignment to any MHMR Tarrant facility as determined by program needs and /or the Division/Director.

Assigned work hours may change as the needs of the agency change.

The functional Title of this position may change as the needs of the agency change.

All work will be complete within the scheduled work hours. All non-exempt (hourly) employee are expected to clock In and out for each work shift, no work done should be done off the clock.

Prior approval from supervisor is required for all Paid Time Off (PTO) and Overtime.

MHMR reserves the tight to change, and to or eliminate a position as it deems appropriate.

Employment is at will, as well as agency needs may change.

Agency dress code is to be followed at all times.

Physical on-site presence, including regular attendance and punctuality is an essential function of this position. Any change or adjustments to your assigned work schedule or shift hours must be approved by your supervisor in advance.

Our Benefits:

Our total rewards program offers benefits* to full time employees beginning 1st of the month following hire date including but not limited to:

• Comprehensive healthcare options (Medical, Dental, and Vision)

• Life insurance and additional supplemental accident and hospitalization plans

• 401a match and 457 deferred compensation plans

• Paid vacation and holidays; varied flexible work environment locations

• Annual tuition reimbursement program

• Student Loan Forgiveness

• Professional development programs and training

• And more.....

Insurance eligibility:

• Full time employees begin 1st of the month following hire date

• Market driven positions (full time or part time) begin immediately after hire date

• Select part time market driven positions are eligible for most insurance plans

• Substitute status jobs are not eligible for benefits

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Additional Information
*MHMR of Tarrant County (MHMR) and its affiliates and subsidiaries have an internal recruiting department. MHMR may supplement that internal capability from time to time with assistance from temporary staffing agencies, placement services, and professional recruiters herein after referred to collectively as Recruiters). Recruiters are hereby specifically directed NOT to contact MHMR employees directly in an attempt to present candidates - MHMR recruiting team or other authorized MHMR personnel must present ALL candidates to hiring managers. For more information please visit our website