THE MISSION OF PROJECT HOME
The mission of the Project HOME community is to empower adults, children, and families to break the cycle of homelessness and poverty, to alleviate the underlying causes of poverty, and to enable all of us to attain our fullest potential as individuals and as members of the broader society. We strive to create a safe and respectful environment where we support each other in our struggles for self-esteem, recovery, and the confidence to move toward self-actualization.
Project HOME achieves its mission through a continuum of services comprised of street outreach, a range of supportive housing, and comprehensive services. We address the root causes of homelessness through neighborhood-based affordable housing, economic development, and environmental enhancement programs, as well as through providing access to employment opportunities; adult and youth education; and health care.
Project HOME is committed to social and political advocacy. An integral part of our work is education about the realities of homelessness and poverty and vigorous advocacy on behalf of and with homeless and low-income persons for more just and humane public policies.
Project HOME is committed to nurturing a spirit of community among persons from all walks of life, all of whom have a role to play in making this a more just and compassionate society.
THE VALUES OF PROJECT HOME
The work of Project HOME is rooted in our strong spiritual conviction of the dignity of each person.
We believe that all persons are entitled to decent, affordable housing and access to quality education, employment, and health care.
We believe in the transformational power of building relationships and community as the ultimate answer to the degradation of homelessness and poverty.
We believe that working to end homelessness and poverty enhances the quality of life for everyone in our community.
We believe that the critical resources entrusted to us to achieve our mission must be managed honorably and professionally.
Job Summary: The Registered Nurse (RN) Care Manager provides a holistic, trauma informed and patient-centered approach in caring for patients at the Hub of Hope Clinic, which serves adults who are homeless and seeking healthcare services at the clinic. Principle roles include:
- Serve as a key member of the clinic team and instrumental to its success.
- Work closely with clinic administrator, providers, medical assistants and behavioral health provider on coordinated intake assessments, goal-setting, and plans of care.
- Serve as coordinator of health services for patients including Medication Assisted Treatment services if applicable, medical, dental and behavioral health providers, health insurance plans, and hospital-based service providers.
- Assess, triage and respond to residents with acute, chronic, and preventive health and wellness needs.
Essential Duties and Responsibilities
- Serves as the primary care coordinator between the patient, the patient’s medical providers, behavioral health provider, pharmacist, dentist, hospital-based service providers, financial assistance specialist, residential and/or behavioral case manager, peer specialist, visiting nursing agency, community health worker and/or other specialists
- Demonstrates excellence in care management by coordinating care with intensive emphasis during care transitions
- Participates in regular team meetings for case review and discussion of evidence-based chronic disease management, integrated care best practices
- Facilitate individual or group sessions which provide education to staff and residents on health-related topics and activities that enhance recovery and self-care management.
- Manages a panel of patients receiving injectable medications at the HUB of HOPE clinic for chronic disease management including antipsychotics and non-insulin injectable diabetes medications
Direct Clinical Care
- Provides nursing assessments and triage to walk-in patients as well as handles in-coming “sick” calls from patients per the Hub of Hope triage protocol
- Educates and counsels patients and their families about issues including, but not limited to, medications, disease and disease management, stress reduction and healthier life-style choices
- Assists during clinic sessions with wound care, clinic procedures, vaccinations and other injections
- Performs AIMS assessments
- Facilitate scheduling of appointments & procedures such as colonoscopies, biopsies, radiology studies, chemotherapy, lab testing, medical/dental/psychiatric evaluations and other health-related activities.
- Obtain prior authorization for medications, procedures, or other services as needed
- Assess the need for durable medical equipment and collaborate with PCP, medical home, insurer, pharmacy, and/or medical supply company to obtain necessary items.
- Collaborate with Program Manager and other key stakeholders to identify areas for improvement.
- Participate in Project HOME/PHHS Quality Improvement initiatives.
- Attend all mandatory Project HOME/PHHS mandatory trainings and/or trainings recommended by Direct Supervisor(s).
- Maintain nursing licensure and CPR certification.
- Bachelor of Science in Nursing (BSN)
- Active RN license in Pennsylvania
- CPR certification
- Three years of relevant work experience
- Knowledge and prior practice of trauma informed care
- Prior experience as a Nurse Care Manager in a primary care setting
- Prior experience delivering services to patients who have experienced homelessness, mental illness, and/or substance dependence, often complicated by histories of trauma.
- Strong computer, organizational and administrative skills.
- EHR experience
Project HOME is an Equal Opportunity Employer. All offers of employment are contingent on successful completion of a drug screen and background checks.
Project HOME reserves the right to revise or change job duties and responsibilities as needed. This job description is not meant to be an all-inclusive statement of the duties and responsibilities of the job nor does it constitute a written or implied contract.