Behavioral Health Home Nurse (RN) - Registered Nurse New

Position Summary

The BHH Nurse’s main responsibility is to work closely with the Health Home Manager to develop the BHH program through the enrollment of eligible youth and the provision of care coordination focused on the assigned youth’s physical health and wellness.

 The BHH Nurse identifies eligible youth for BHH by participating in the screening process of all Medicaid-enrolled CMO youth and following up on referrals provided by Care Management staff. The BHH Nurse conducts initial nursing assessments with families and verifies the youth’s BHH eligibility by confirming diagnoses with the youth’s medical providers. The BHH Nurse also completes annual Nursing Assessments for all BHH enrolled youth to confirm ongoing eligibility for the service.

 The BHH Nurse also partners with the Care Manager in the provision of Wraparound services and the Child Family Team Process. The Nurse specifically focuses on providing wellness education and medical care coordination to the youth and families that we serve. This entails meeting with the youth and family in person to provide wellness education and collaboration with clinical, community, and medical services related to the youth’s medical conditions. The Nurse develops a Quarterly Progress Update (QPU) with the family to monitor wellness goals and progress. The Nurse is responsible for the accurate and timely submission of documentation that reflects the work that is done with the families.  To perform this job successfully, the Nurse must interact with system partners, including but not limited to schools, Juvenile Justice, Child Welfare, clinical and substance use disorder providers, the Family Support Organization, and other formal and informal supports that benefit the family.

Key Responsibilities

• Advance the mission and values of Capitol County Children’s Collaborative (CCCC) on behalf of staff, children and families, and system partners.
• Ensures compliance with all State and Federal confidentiality laws, including but not limited to the HITEC and HIPAA.
• Attends all CCCC and CSOC required meetings and training, including but not limited to monthly staff meetings, CCCC committee meetings, community resource events, Wraparound training, and any other ongoing training deemed necessary by CCCC. In-person attendance is required as designated by CCCC management.
• Serves as a member of the CCCC’s management team.
• Contact any newly referred youth and family in person within 72 hours, begin the process of obtaining release of medical records and schedule the initial nursing assessment.
• Completing enrollment of new families, including determining eligibility by conducting Initial Nursing Assessment and confirming diagnosis with the youth’s medical providers within the first month of referral.
• Completes annual nursing assessments for all BHH-enrolled youth.
• Become proficient in the Wraparound model and process as the standard of care management delivery.
• Contact all newly enrolled BHH families within 72 hours of being assigned to the Nurse for ongoing BHH care coordination
• Conduct two in-person meetings, the first month of being assigned the youth; one visit must occur in person, where the Initial Quarterly Progress Update (QPU) is developed with the family
• Participate in the Child Family Team to help develop self-management health goals to be included in the service plan.
• Provide health education specific to the chronic conditions of the assigned youth,
• Engage assigned children and families in health promotion planning and activities to increase treatment and medication compliance, support lifestyle changes, and develop a health and wellness plan with the family; engagement includes a minimum of three monthly contacts a month, one of which is required to be done In-person
• Coordinate the youth’s care throughout the month with a minimum of two contacts with the Care Manager and at least one contact with another team member (ie. FSO, clinician, school)
• Submit completed documentation for CYBER and the Digital Data Recording System (DDRS) on a timely basis.
• Participate in the development and facilitation of the agency’s Wellness Committee, promoting health and wellness among staff members
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Knowledge

• BHH Nurse must have familiarity with the following:
• Common pediatric health concerns, including but not limited to obesity, asthma, and diabetes
• Intellectual developmental disability 
• Substance use
• Child behavioral health and welfare system, including cultural/ethnic/gender/class issues
• Child welfare system
• Juvenile justice
• Mental health diagnosis
• Familiarity with ethical considerations and regulations related to mental health and child welfare
• Knowledge of the educational system, including special education       

Skills And Abilities

• Use of Agency technology tools - CYBER, MS Office365, Mercer Resource net, Digital Data Recording System (DDRS), and other collaborative tools as identified by CCCC
• Excellent oral and written communication skills
• Engagement and Conflict Management resolution skills
• Active Listening skills
• Cultural Awareness/Cultural Humility
• Applies a problem-solving focus to day-to-day work

Qualifications: Education and Experience

• RN
• 1 year of experience working in the community
• 2 years’ experience working with youth and families with behavioral and mental health challenges
• Clinically and culturally competent/responsive with training and experience necessary to manage complex situations of children and families in the community across child-serving systems.
• CPR/BLS certification required
• Case management experience preferred
• Bilingual skills preferred

Other Qualifications (certification, licensure, etc.)

• A valid US driver’s license is required.
• Annual CARI checks are required
• Pre-employment and ongoing background checks and regular motor vehicle record checks are required
• Bilingual skills preferred