The RN Care Manager/Patient Education Specialist oversees the development of community health promotion and education services which encourage and support healthy living concepts to motivate patients to adopt healthy behaviors and promote self-management of their health and wellness. The RN Care Manager/Patient Education Specialist also provides education and support to patients with chronic medical conditions, including HIV/AIDS, with or without co-morbid health diseases like diabetes, cardiovascular disease and obesity. In partnership with the patient and medical staff, the RN Care Manager/Patient Education Specialist develops a care plan that is the right fit for the patient’s condition(s) to ensure needed access to medical, behavioral, and dental services and education/supports on self-management of medical condition(s). Further, the RN Care Manager/Patient Education Specialist works collaboratively with Community Outreach Workers to provide education, outreach and support to the community as well as patients served. The RN Care Manager/Patient Education Specialist for the Ryan White Programs will manage care in accordance with the Ryan White Grant Contracts.
EDUCATION AND EXPERIENCE/QUALIFICATIONS
Nursing degree from an accredited nursing school plus 3 years of progressively responsible experience providing nursing services to adults from diverse economic and cultural backgrounds, as well as exceptional communication, interpersonal and organizational skills are required. Experience with care management in primary care settings is preferred. Bi-lingual English/Spanish a plus.
Licensure Requirements for Clinical Positions
Credential(s) Required: Current State of Connecticut Unencumbered Registered Nurse License.
Wheeler provides equitable access to innovative care that improves health, recovery and growth at all stages of life.
Wheeler Clinic offers access to a comprehensive array of benefits, including:
For Good Health
- Anthem Medical, Prescription, Dental and Vision insurance
- Health Savings Account (HSA), with company contribution of up to $1,000 per year
- Wellness Programs
- Free annual flu shots
For a Secure Future
- Company paid Life and AD&D insurance
- Company paid long-term disability insurance
- 403(b) Plan, with clinic contributions for eligible employees
For Career Advancement
- Education Reimbursement Program
- Training and development opportunities
For Work Life Balance
- Generous paid time off, including vacation, sick and personal leave
- Employee Assistance Program (EAP)- Free and confidential counseling
- Employee discounts at local spa and on cell phone services
ESSENTIAL DUTIES AND RESPONSIBILITIES
Provides care management transportation assistance, health and nutrition screenings to patients with HIV/AIDS who present to the Health/Wellness Center for care.
Develops, in consultation with the patient and the Medical staff, a comprehensive, person-centered care self-management plan that includes all medical, behavioral health, and dental relevant information in accordance with Ryan White Contracts.
Provides health education and wellness interventions specific to patients with HIV/AIDS.
Educates patients and/or family members on the importance of preventative and wellness/health-promoting lifestyle interventions, such as immunizations, promotion of health screenings, smoking prevention and cessation, nutritional counseling, obesity reduction and prevention, increasing physical activity, treatment adherence, medication adherence, substance use prevention/early intervention and harm reduction and promoting independence and skills development related to disease self-management and self-administration of medications.
Identifies and/or develops education and supportive interventions to increase patients’ skills and confidence in managing their health, including regular assessment of progress and setbacks, goal setting, and problem-solving support.
Participates with regular staff meetings focused on coordinating care within an interdisciplinary team, providing the team updates on patients’ progress in care.
Maintains and updates care plans in accordance with Ryan White Contract requirements, working to maintain client engagement, treatment adherence counseling, client specific advocacy, review of utilization of services at regular intervals, updating patient’s ongoing familial, friend or other personal support systems and updating the care plan with this information at least every six months, more frequently with each comprehensive visit as needed.
Makes referrals for housing services for short term, long term or emergency, temporary or transitional housing as needs arise, in addition to food bank/home delivered meals, health insurance maintenance and applications, Ryan White program eligibility screenings, legal assistance, vocational assistance referrals, and basic needs referrals in accordance with Ryan White Contracts.
Engages patients in health and wellness primary care services, psychosocial support services, continuum of care, oral health services with internal referrals or external referrals as appropriate, medical nutrition screenings and nursing education related to nutrition and diet, referrals for mental health services, and substance abuse services.
Must be able to pass a respirator fit test at time of hire and on an annual basis.
Performs job responsibilities consistent with standards for best practice nursing, including excellent communication with all providers to ensure the delivery of high quality care.
Follow-up with external medical providers when barriers to care are identified.
How to Apply