The RN Care Coordinator is responsible for providing
care coordination and case management services, following established standards
and practices within the scope of their licensure, to Phoenix House Health &
Recovery Solutions patients receiving Medication for Opiate Use Disorder (MOUD),
formally referred to as Medication Assisted Therapy.
The RN Care
Coordinator at Phoenix House Health & Recovery Solutions is accountable to:
- Managing their day-day clinical, administrative,
operational and fiscal responsibility as it relates to patient care
- Ensuring uniform implementation and execution of
Phoenix House policies, procedures and protocols
- Actively assisting the Phoenix House Executive
Leadership Team with the administration of Phoenix House New England'sstrategic
plans and goals
DUTIES AND RESPONSIBILITIES
- Health Home Service/Activities:
Team with a Clinical Care Coordinator to provide health home
service to a panel of 100 MOUD patients (per Full-Time Equivalent of care
coordination). Minimum requirement
is an "auditable record of at least one health home service per
patient each month." Establish
mapping for the six health home services in each clinical record system
that the MOUD team can use.
Activities undertaken to identify patients for Medication for
Opiate Use Disorder, conduct initial assessments, and formulate individual
plans of care. Also includes
activities related to managing and improving the care of the patient
population across health, substance abuse and mental health treatment, and
social service providers.
Care Coordination: Implementation of individual plans of
care (with active patient involvement) through appropriate linkages,
referrals, coordination and follow-up as needed to services and supports
across treatment and human services settings and providers. The goal is to assure that all services
are coordinated across provider settings, which may include medical,
social, mental health, substance, corrections, educational, and vocational
of potential MOUD patients via referrals, prior authorizations, VT
Chronic Care Initiative (VCCI) risk stratification, claims and
utilization data, judicial referrals for treatment, and outreach to
patients lost to contact
of preliminary services needs; treatment plan development; including
of health team roles and responsibilities
treatment guidelines and protocols for health teams to use in specific
practice settings (primary care, specialty care) for transitions of care,
identified health conditions (e.g. opioid dependence with depression or
chronic pain), and prevention and management of substance relapse
MOUD patient's health status, treatment progress, service use to improve
care and address gaps in care
and use data to assess use of care guidelines in practice settings,
patient outcomes, and patient experience of care
and implement quality improvement activities to improve the provision of
care (learning collaborative, PDSA cycles)
that promote patient activation and empowerment for shared decision-making
in treatment, healthy behaviors, and self-management of health, mental
health, and substance use conditions.
scheduling, outreach to support attendance at scheduled treatment and human
referrals and follow-up monitoring, participating in discharge planning
from hospital, residential, and corrections
with other providers and family members
treatment progress and implementation of the individual care plan
management necessary for individuals to access medical, social,
vocational, educational, substance abuse and/or mental health treatment
supports, and community based recovery services
with other providers to monitor individual's health status and
participation in treatment
medication adherence and calculating medication possession rates
of all medications being prescribed, communication with prescribers, and
to and assistance in maintaining safe and affordable housing
outreach to family members and significant others in order to maintain
individual's connection to services and expand their social network
Care coordination focused on planned, seamless transitions of care
through streamlining the movement of patients from one treatment setting
to another, between levels of care, and between health and specialty MH/SA
service providers. Goals are to
reduce hospital readmissions, facilitate timely development of community
placements, and coordinate the sharing of necessary treatment information
health education specific to a patient's chronic conditions
of health education specific to opioid dependence and treatment options
health and life goals and development of self-management plans with the
interviewing and other behavioral techniques to engage patients in
healthy lifestyles and reduce substance use
for management of chronic pain
for smoking cessation and reduction of use of alcohol and other drugs
health promoting lifestyle interventions including but not limited to
nutritional counseling, obesity reduction, and increasing physical
support to develop skills for emotional regulation and parenting skills
support for improving social networks
and Family Support:
Assisting individuals to fully participate in treatment, reducing
barriers to access to care, supporting age and gender appropriate adult
role functioning, and promoting recovery.
and maintaing collaborative relationships between health home providers
and other entities such as hospital emergency departments, hospital
discharge departments, corrections, probation and parole, residential
treatment programs, primary care providers, and specialty Mental
Health/Substance Use treatment services
and implementing referral protocols including standardized clinical
treatment information on electronic and paper Continuity of Care
and using data to identify MOUD clients with patterns of frequent ED,
Hospital, or other relapse-related services utilization and planning
systemic changes to reduce use of acute care services
to Community & Social Support Services: Assisting clients, obtain and maintain
eligibility for formal supports and entitlements (e.g. health care, income
support, housing, legal services) and to participate in informal resources
to promote community participation and well-being.
individual and family strengths and needs
outreach and supportive counseling to key caregivers
information about services and formal and informal resources, and
education about health conditions and recommended treatments
assistance with navigating the health and human services systems
assistance with obtaining and adhering to prescribed treatments including
participation in ongoing development and revisions to individual plan of
Health Home Quality Measures:
Tracking and reporting Health Home Quality Measures. The program requires that Health Homes
select from established HEDIS measures to measure outcomes and quality.
and maintaining up-to-date local information about formal and informal
resources beyond those covered in the Medicaid plan, including peer and
and supporting access to community resources based on individual patient
needs and goals
patients, obtain and maintain eligibility for income support, health
insurance, housing subsidies, and food assistance
information and supporting participation in vocational and employment
services to promote economic self-sufficiency
- Measure 1: Self-Management for
any chronic condition (including opiate dependence)
- Measure 2: Adult Body Mass Index
- Measure 3: Age and gender
appropriate health screenings
- Measure 4: Screening for Clinical
Depression and Follow-Up Plan - Percent screened for clinical depression
using standardized tool with follow up documentation
- Measure 5: Initiation and Engagement
of Alcohol and Other Drug Dependence Treatment
- Measure 6: Alcohol Misuse
Screening - Annual screening with AUDIT-C and documentation
- Measure 7: Tobacco Cessation
Screening - Receipt of advice to quit smoking
- Measure 8: Tobacco Cessation
Screening - Receipt of information on smoking cessation medications
Measure 9: Care Transition - Transition Record Transmitted to Health Care
- Measure 10: Care Transition -
Transition Records - receipt of transition record at time of discharge
with specified elements
- Measure 11: Care Treatments -
Receipt of reconciled medication list
- Be responsible
for creating a safe and accident-free environment. Safety comes first over all
communicates with the patient and the family/support system about the treatment
plan, resources and required follow up care.
the Phoenix House of New England's electronic health record by appropriately
documenting all patient interactions ensuring to include all necessary
documentation and coding is comprehensive and complete to support both quality
of care and revenue cycle.
participates in program committees and maintains both a collegial and independent
relationship with members of the medical staff and clinical/administrative
support of and assists with the execution of cost saving process improvement initiatives.
with other programs and team members to ensure efficient flow of patients.
pride in ones' environment by helping to maintain an organized,
uncluttered and clean workplace.
with and reports any programmatic safety concerns through on-site
observation, incident report generation and/or review, root cause
analysis, best practice review and implementation training to improve
programmatic and organizational standards.
with and report quality improvement needs through review of Patient
Satisfaction Survey reviews and other identified and developed tools.
with Directors related to implementing and maintaining structure &
accountability related to organizational goals, values and mission.
and report programmatic implementation of policies, procedures and best
and/or Facilitate necessary trainings related to identified programmatic
and/or organizational needs.
accurate, timely, legible clinical & clerical notes. Document developments and important
events in accordance with clinical policies for reporting and record
keeping. Use Phoenix House systems,
including Electronic Health Record (EHR), effectively and appropriately.
30, 60, 90-day Self -performance supportive review documentation as required.
all necessary DATIS files, timecards and e-learning Relias requirements in
a timely fashion.
cooperatively with supervisor and team members.
all notes in a timely manner.
with supervisor on a regular basis.
as a rolemodel through positive,
appropriate conduct and participation in special agency events. Project a good image to the public.
in a professional manner.
other duties as assigned by direct supervisor or designee.
SKILLS & ABILITIES
this position successfully, you must be able to perform each essential duty and
Reasonable accommodations may be made to enable individuals with
disabilities to perform the essential duties and responsibilities. The requirements listed below are representative
of the knowledge, skill and/or ability required.
Use AIDET during patient encounters:
Acknowledge, Introduce, Duration, Explanation, Thank-You
Find a way to say YES to patients/customers
and co-workers or be responsible for finding someone who can assist if I am
unable to in that moment.
Excellent communication and collaboration
Proven critical thinking and problem solving
Ability to establish a therapeutic
relationship with patients and support resources (family or friends)
Strong organizational skills with ability to manage
numerous cases effectively
Strong team building skills
Ability to effectively use computer software;
web-based applications for assessing and managing addiction
Ability to provide self-management support
Skilled at process and clinical outcomes
improvement using quality improvement methodologies, including tracking and
Knowledge of the treatment of co-occurring
populations and MOUD as appropriate.
Extensive knowledge of the daily operations of
a not-for-profit substance use and mental health disorder health facility.
Ability to prioritize conflicting
demands/expectations as well as to multi-task effectively for sustained periods
Ability to apply organizational management
skills and maintain self-discipline.
Ability to collaborate and build successful
relationships with others to ensure objectives and goals are met.
Communication skills both written and verbal as
well as the understanding of the principals of communication in multiple
directions, vertically, horizontally and laterally.
Problem solving skills with a collaborative
Knowledge of Continuous Quality Improvement
process and Performance Improvement program design and implementation.
Proficiency in using Phoenix House systems,
including Electronic Health Record system to document notes and activities as
necessary is expected within 30 days of employment.
Skill in representing the organization
internally and externally.
Ability to provide support and direction to
program staff, volunteers and interns.
The ability to be forthcoming with
information and/or personal challenges to ensure the facility Program Director
and Vice President has an accurate awareness of any issues that may impact him/her
or his/her program as well as his/her staff or other members of PH.
Be Accountable and Dependable.
Maintain objectivity towards all patients and
make decisions based on accurate information.
Utilize Trauma Informed best practices with patients
and staff to promote effective and safe coping skills and self-
Demonstrate appropriate boundaries between
self and staff/patients.
Knowledge of rules and regulations related to
HIPPA and 42 CFR Part 2.
Ability to comply with internal, local, state,
and federal regulations and policies.
Ability to promote and demonstrate "Every
Time Behaviors" Teamwork model.
Ability to promote and demonstrate Phoenix
House's ICARE4 core values (Integrity,
Collaboration, Accountability, Respect, Excellence, Forward Thinking) through
work ethic, compliance, and attitude:
Willingness to Help
an Accredited School of Nursing with a BSN required. MSN or other relevant
Master's degree preferred.
Valid VT RN license
required. Case Management certification
preferred. Valid Driver's License and
automobile insurance required.
demands described here are representative of those that must be met by an
employee to successfully perform the essential duties and responsibilities of
this position. Reasonable accommodations
may be made to enable individuals with disabilities to perform the essential
duties and responsibilities.
REGULARLY REQUIRED: to sit, use hands to finger, handle or feel
objects, tools or controls; reach with hands and arms, and talk or hear.
OCCASIONALLY REQUIRED: to
stand, walk, stoop, kneel or crouch and lift and/or move up to 10 pounds
The work environment
characteristics described here are representative of those an employee
encounters while performing the essential duties and responsibilities of this
position. Reasonable accommodations may
be made to enable individuals with disabilities to perform the essential duties
The work environment is that of a substance use
and mental health disorder treatment milieu which may include:
Exposure to and contact with patients under a
variety of circumstances whose exposure elements may include infection with
Hepatitis B, C, HIV, TB, or other Infectious and contagious Diseases.
Exposure to patients with co-occurring mental
Weekend and holiday hours
First, second, and/or holiday shifts may be
Phoenix House is an Equal Opportunity Employer providing equality of
opportunity to all who are protected against discrimination by law,
regulation or executive order, including veterans and individuals with
disabilities. EEO is the Law: Applicants and employees are protected
under Federal law from discrimination. Click www.dol.gov/ofccp/regs/compliance/posters/pdf/eeopost.pdf
to learn more.