Nurse Case Manager

Summary: Under the direction of the case manager supervisor and directors, the nursing case manager provides an expansive range of intensive client-centered case management and nursing services. They work closely with the client's care team to coordinate interdisciplinary care and provide resources to address barriers to care and adherence. They will also coordinate care with home providers. They provide linkage and referrals to multiple services, including housing, food, mental health and substance use care, dental, eye care, legal, transportation and social service support. They assist with enrolling in insurance, ADAP and entitlements. They provide contact by phone, text, email, as well as in-person visits in the office, clinic and hospital. They provide all assessments and reassessments required. They provide triage and linkage services in the office and clinic, as well as via phone. They assure all case managed clients are receiving medical care. They prioritize respectful trauma-informed care related to all cultures and group affiliations, including LGBTQ, elders, African Americans and other people of color, women, those living in poverty, recently incarcerated, adolescents and young adults, those with learning or language barriers, those with mental health issues, and those who use substances.

Duties:

• Provides assistance with accessing and identifying resources for those living with HIV, including entitlements, community treatment providers, Medicaid, ADAP, marketplace insurance, housing, transportation, support groups, food, prescriptions and shelter.
• Performs initial assessment interview in person with clients including psychosocial needs and at home safety needs. Provides reassessment every six months and when changes occur.
• Develops treatment plan in accordance with established policies and procedures and compliant with the AFC Northeastern Illinois HIV/AIDS Case Management Cooperative Agreement policies, Department of Rehabilitation Services (DRS), the Department of Children and Family Services, and the Joint Commission on Accreditation of Healthcare Organizations.
• Provides triage to clients who walk-in, or contact via phone, email, MyChart, etc.
• Assists walk-in clients and those who have missed appointments to reconnect to care, by decreasing barriers to care, including medical visits and lab services.
• Provides nursing care including medication management, injections, and treatments.
• Assures timely follow-up communication with community providers, including post-hospital and ER discharge, outside primary or specialty care, post-incarceration, nursing homes, etc.
• Manages prior authorizations, medication refills and ordering of medical equipment and treatments.
• Conducts outreach services.
• Provides patient, family and community education and support.
• Maintains resource list of community services related to shelter, state and federal entitlements, housing, food and support services.
• Maintains current information and requirements related to issues of domestic/family violence, substance use, mental illness, and child welfare (DCFS) and elder abuse.
• Assumes responsibility for meeting with each client individually to develop a signed treatment plan, complete assessments and reassessments, complete acuity rating and update demographic information as needed, at minimum every six months.
• Prepares case presentation for staff meetings and treatment planning.
• Prepares documentation and records for court appearances when needed.
• Keeps all documentation in accordance with AFC, State of Illinois and HRSA case management standards. Documents all activities immediately after patient encounter in each client's chart. Completes releases of information, and enters signed receipts and all required forms in the client level database in a timely manner. Submits reports to the data manager. Maintains access to electronic case management and medical records.
• Documents all nursing visits and triage in the electronic medical record and client level data as required by UI Health and Chicago Department of Public Health (CDPH).
• Participates in no less than twelve professional development sessions yearly, including cultural competency, and in UIC, AIDS Foundation of Chicago and CDPH required meetings.
• Participates in case management collaborative activities with other service providers to foster care, communication, cooperation, and service delivery.
• Participates in monthly clinical supervision. Other supervision as assigned or requested.
• Maintains ethical standards of the profession and hospital policies regarding employee standards of conduct as described by Hektoen Institute and University of Illinois including confidentiality and HIPPA requirements.
• Works closely, cooperatively and in a professional manner with all staff including appropriate sharing of information, and training new staff members and students.
• Is prepared to assist with additional responsibilities when staff members are absent, or emergency coverage including cross coverage when assigned by the supervisor. For example, DRS case management services.
• Attends the various meetings during the week, i.e. staff meetings and case management meetings. Participates in environmental training, infection control, fire, safety and all mandated training. Participates in educational programs for HIV, mental health and substance use, special populations, cultural respect, and other topics as needed, required for certification and as directed by supervisor.
• Participates in QM and QI activities as directed, including but not limited to participation in client surveys, focus groups, site visits, and QM committee.
• Must document daily and always on a timely basis.
• Maintains level of productivity to meet scopes of service and required caseload.
• Assists with preparation for site visits
• Participates in grant writing as needed
• Performs other duties as assigned or requested

Qualifications:

• Bachelor's degree in nursing
• Illinois nursing license (or planning to take boards within 3 months)
• Experience and demonstrated respect working with those from diverse communities and age groups
• Must maintain strict confidentiality and privacy in accordance with all applicable laws, statutes and standards
• Must complete AFC medical case management training when hired
• Excellent spoken and written communication skills
• Willing and able to fully participate in multidisciplinary team
• Experience with diverse populations and those experiencing mental health or substance use issues is a plus

Salary Range: 73,000 to $83,000