RN Case Manager - KidsFirst/MCH

Working title: Registered Nurse Case Manager         

Classification title: Registered Nurse                           

Division: Client Health Services

Program: KidsFirst and Maternal Child Health

FLSA status: Non-Exempt: Part-Time 32 hours                                        

Reports to: WIC/FHS Program Manager 1

Schedule: Monday-Friday 

Wage Range: $34.52 to $55.60 hourly; depending on number of years of transferrable experience and internal equity

 Organizational Overview

Serving the Yellowstone County community and south-central Montana for nearly 50 years, RiverStone Health is an essential provider of personal and public health services. Health, Education, Leadership and Protection – HELP is what we do. From medical, dental and behavioral healthcare; home care and hospice; public health services like immunizations, WIC, health promotion and restaurant inspections; and educating the next generation of health professionals, our expertise spans all ages and stages of life.  Underlying principles of access, affordability, compassion and quality in all interactions, RiverStone Health improves life, health and safety for all of the communities we serve.

Division and Program Overview: 

Family Health Services (FHS) programs are available to pregnant people, families with infants, pre-school age children and children up to the age of 18 with special healthcare needs.  Alone or in combination, a team of nurses and resource workers help families to reach their goals to improve their family’s life, health, and safety. This is a grant funded program which is subject to annual renewal.

Job Summary:

This is a position in which the KidsFirst and Maternal Child Health Registered Nurse Case Manager positions are combined, serving pregnant people, children and families across Yellowstone County.

KidsFirst Registered Nurse Case Manager:

KidsFirst Program strives to provide coordinated care to work with all systems that impact children in foster care including but not limited to the foster care system, physical and behavioral healthcare, and families or caregivers to ensure the healthcare needs of children in foster care are met. 

 Maternal Child Health Registered Nurse Case Manager:

Maternal Child Health (MCH) Program provides comprehensive nursing services to pregnant women and/or children up to the age of 18. The nurse adheres to the department guidelines while educating, connecting with and providing referrals and resources to clients.

Essential Functions/Major Duties and Responsibilities:

Nursing Services 60%

• Welcomes client/family, establishes rapport and answers any questions regarding treatments, immunizations, beneficial health practices, disease prevention, or care plans.  Responds to client’s questions and comments in a courteous and timely manner.  Accommodates language or literacy barriers and special needs of clients/caregivers to make them feel comfortable and informed about procedures.
• Provides case management and health education services to clients and their families in the community, their homes, personal care homes, or specialized programs.
• Makes initial client evaluation visit and assessment, including taking client medical histories. Performs regular follow-up assessments of clients’ status and adjusts treatments as necessary. Maintains documentation such as clinical and progress notes, vaccine records, treatment plans, and maintains other appropriate records.
• Informs the primary medical provider of any changes in clients’ condition or needs and coordinates any modifications in treatment with other appropriate personnel.
• Assesses and determines the physical, social, and environmental needs of clients and develops a plan of treatment with other team members.
• Provides skilled comprehensive nursing assessment and facilitates health care plans, access to immunizations, and treatments for clients. 
• Communicates and coordinates regularly with appropriate others to maximize the effectiveness and efficiency of interagency operations and activities. Participate in program quality improvement projects.
• Keeps immediate supervisor and designated others accurately informed concerning work progress, including present and potential work problems and suggestions for new or improved ways of addressing such problems.
• Attends meetings, conferences, workshops, and training sessions and reviews publications and audio-visual materials to become and remain current on principles, practices, and new developments in assigned work areas.
• Uses skilled nursing services to meet requirements of Public Health activities as needed.

KidsFirst/Maternal Child Health Services 35%

• Conducts unaccompanied home visits at client/family residences, foster homes or other public settings.
• Provides on-going emotional support and acts as an advocate for clients with other community support services and organizations.
• Assesses and determines the physical, social, and environmental needs of clients.
• Develops a plan of treatment with other team members.
• Completes initial client evaluation visit and assessment, including obtaining client medical histories.
• Prepares clinical and progress notes and maintains other appropriate records.
• Coordinates the agency’s services with those of other community agencies and makes appropriate referrals.
• Acts as liaison between client and other agencies when client is referred elsewhere.
• Company cell phone will be provided for client communication purposes.

Non-Essential Functions/Other duties as assigned                                        5%

• Perform other duties as assigned in support of the organization’s mission and goals.

Education and Experience:

Minimum Qualifications

• Associate degree in nursing
• 3-5 years’ experience in patient care.
• Certification by the American Heart Association (AHA) for Basic Life Support (BLS)
• Any combination of experience and training which provide the equivalent scope of knowledge, skills, and abilities necessary to perform the work.

Preferred Qualifications:

• Bachelor’s degree in nursing
• Maternal or child health experience
• Experience working with underserved populations

Certificates, Licenses, Registrations:

• Current license as a Registered Nurse in the State of Montana
• Valid State of Montana Driver’s License and vehicle insurance
• BLS Certificate

Knowledge, Skills, and Abilities:

• Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction.
• Thorough knowledge of nursing techniques and their relation to medical and surgical practice.
• Knowledge of public health principles and practices, preventive measures, and knowledge of community resources.
• Knowledge of the skills necessary to provide care appropriate to clients served.
• Knowledge and understanding of protected sensitive client health information (HIPAA) and confidentiality.
• Strong communication and listening skills.
• Ability to work independently to meet needs of clients.
• Ability to work collaboratively and maintain a positive work environment.

Customer Service Excellence:

• Doing things right the first time
• Making people feel welcome
• Showing respect for each customer
• Anticipating customer needs and concerns
• Keeping customers informed
• Helping and going the extra mile
• Responding quickly
• Protecting privacy and confidentiality
• Demonstrating proper telephone etiquette
• Taking responsibility for handling complaints
• Being professional
• Taking ownership of your attitude toward Service Excellence.

Supervision:

• None

Physical Demands and Working Conditions:

• Work is 75% performed in the home and community setting.
• Will be exposed to home environments that may include allergens such as smoke, pets, etc.
• Travel is required to client homes or community settings.
• Ability to travel and use own personal vehicle. Expected to drive a vehicle which requires sitting, seeing and reading signs, traffic signals, other vehicles, etc. Travel occurs in all weather conditions, including extreme heat and cold.
• Sitting, standing and bending will be required.
• Ability to lift 25 pounds on regular basis.
• Create and maintain a safe/secure working environment by adhering to safety, security, and health requirements. Integrates injury, illness, and loss prevention into job activities by attending any necessary training and implementing best practices.

Freedom to Act & Decision Making:

• Works under the direction of the Program Manager and Client Health Services Nursing Director.  Work is structured by public health regulations and established nursing practices.  The position makes independent professional judgements regarding client health.  Decisions directly affect the quality of services provided to the public.

Communications & Networking:

• Daily written and verbal communication with clients and other RiverStone Health staff.
• Work directly with other team members to provide quality customer service for clients and customers.
• Works with community agencies to connect clients with resources.

Budget & Resource Management:

• None

ADDENDUM: Public Health Accreditation Requirements

COMPETENCIES AND SKILLS:  Staff’s skill levels must align with priority Core Competencies for Public Health Professionals’ appropriate for the staff, Tier 1 level^[1]. 

Analytical/Assessment Skills

•  Describes factors affecting the health of a community (e.g., equity, income, education, environment)
• Selects comparable data (e.g., data being age-adjusted to the same year, data variables across datasets having similar definitions)
• Describes public health applications of quantitative and qualitative data
•  Contributes to assessments of community health status and factors influencing health in a community (e.g., quality, availability, accessibility, and use of health services; access to affordable housing)
•  Explains how community health assessments use information about health status, factors influencing health, and assets and resources

Policy Development/Program Planning Skills

• Contributes to state/Tribal/community health improvement planning (e.g., providing data to supplement community health assessments, communicating observations from work in the field)
• Contributes to development of program goals and objectives
• Describes organizational strategic plan (e.g., includes measurable objectives and targets; relationship to community health improvement plan, workforce development plan, quality improvement plan, and other plans)
• Contributes to implementation of organizational strategic plan
• 2A5 Identifies current trends (e.g., health, fiscal, social, political, environmental) affecting the health of a community
• Gathers information that can inform options for policies, programs, and services (e.g., secondhand smoking policies, data use policies, HR policies, immunization programs, food safety programs)
• Describes implications of policies, programs, and services
• Implements policies, programs, and services
•  Gathers information for evaluating policies, programs, and services (e.g., outputs, outcomes, processes, procedures, return on investment)
•  Applies strategies for continuous quality improvement

Communication Skills

• Identifies the literacy of populations served (e.g., ability to obtain, interpret, and use health and other information; social media literacy)
• Communicates in writing and orally with linguistic and cultural proficiency (e.g., using age-appropriate materials, incorporating images)
• Suggests approaches for disseminating public health data and information (e.g., social media, newspapers, newsletters, journals, town hall meetings, libraries, neighborhood gatherings)
• Conveys data and information to professionals and the public using a variety of approaches (e.g., reports, presentations, email, letters)
• Communicates information to influence behavior and improve health (e.g., uses social marketing methods, considers behavioral theories such as the Health Belief Model or Stages of Change Model)
• Describes the roles of governmental public health, health care, and other partners in improving the health of a community

Cultural Competency Skills

• Describes the concept of diversity as it applies to individuals and populations (e.g., language, culture, values, socioeconomic status, geography, education, race, gender, age, ethnicity, sexual orientation, profession, religious affiliation, mental and physical abilities, historical experiences)
• Describes the diversity of individuals and populations in a community
• Describes the ways diversity may influence policies, programs, services, and the health of a community
• Recognizes the contribution of diverse perspectives in developing, implementing, and evaluating policies, programs, and services that affect the health of a community
• Addresses the diversity of individuals and populations when implementing policies, programs, and services that affect the health of a community
• Describes the effects of policies, programs, and services on different populations in a community

4A7.      Describes the value of a diverse public health workforce

Community Dimensions of Practice Skills

• Describes the programs and services provided by governmental and non- governmental organizations to improve the health of a community
• Recognizes relationships that are affecting health in a community (e.g., relationships among health departments, hospitals, community health centers, primary care providers, schools, community-based organizations, and other types of organizations)
• Engages community members (e.g., focus groups, talking circles, formal meetings, key informant interviews) to improve health in a community
• Provides input for developing, implementing, evaluating, and improving policies, programs, and services
• Informs the public about policies, programs, and resources that improve health in a community
•  Describes the importance of community-based participatory research

Public Health Sciences Skills

• Describes how public health sciences (e.g., biostatistics, epidemiology, environmental health sciences, health services administration, social and behavioral sciences, and public health informatics) are used in the delivery of the 10 Essential Public Health Services
• Retrieves evidence (e.g., research findings, case reports, community surveys) from print and electronic sources (e.g., PubMed, Journal of Public Health Management and Practice, Morbidity and Mortality Weekly Report, The World Health Report) to support decision making
• Describes evidence used in developing, implementing, evaluating, and improving policies, programs, and services

Financial Planning and Management Skills

• Adheres to organizational policies and procedures
• Describes public health funding mechanisms (e.g., categorical grants, fees, third-party reimbursement, tobacco taxes)
• Provides information for proposals for funding (e.g., foundations, government agencies, corporations)
• Describes financial analysis methods used in making decisions about policies, programs, and services (e.g., cost-effectiveness, cost-benefit, cost- utility analysis, return on investment)
• Operates programs within budget
•  Describes how teams help achieve program and organizational goals (e.g., the value of different disciplines, sectors, skills, experiences, and perspectives; scope of work and timeline)
•  Uses evaluation results to improve program and organizational performance
•  Uses performance management systems for program and organizational improvement (e.g., achieving performance objectives and targets, increasing efficiency, refining processes, meeting Healthy People objectives, sustaining accreditation)

Leadership and Systems Thinking Skills

• Incorporates ethical standards of practice (e.g., Public Health Code of Ethics) into all interactions with individuals, organizations, and communities
• Describes public health as part of a larger inter-related system of organizations that influence the health of populations at local, national, and global levels
• Describes the ways public health, health care, and other organizations can work together or individually to impact the health of a community
• Contributes to development of a vision for a healthy community (e.g., emphasis on prevention, health equity for all, excellence and innovation)
• Identifies internal and external facilitators and barriers that may affect the delivery of the 10 Essential Public Health Services (e.g., using root cause analysis and other quality improvement methods and tools, problem solving)
• Participates in professional development opportunities
• Describes the impact of changes (e.g., social, political, economic, scientific) on organizational practices
• Describes ways to improve individual and program performance

^[1]Council on Linkages between Academia and Public Health Practice