About Primary Health Solutions

Our Mission

We meet people where they are and partner with them on their journey towards wellness.

Our Vision

The destination for servant leaders to provide comprehensive and exceptional care.

Our Values

R – Respect

I – Innovation

S – Stewardship

E – Excellence

Care Manager Summary

The Re-Entry RN Care Manager serves in a dual -role supporting jail re-entry coordination for justice-involved patients and integrated care with a partner behavioral health practice. This role is responsible for facilitating safe, timely transitions of care, reducing gaps in medical and behavioral health services, and improving health outcomes for high-risk populations through comprehensive nursing care management, care coordination, patient education, and interdisciplinary collaboration.

A Day in the Life

This job description reflects management's assignment of essential functions. Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

1. Facilitate care coordination for patients transitioning from jail or other community institutions, ensuring they are linked to primary care services immediately upon release.

2. Complete intake assessments for individuals leaving jail to identify their medical, mental health, and social needs.

3. Formulates and implements a care management plan that addresses the patients identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; educating the patient/family on the choices available. Establishes a care management plan that is mutually agreed upon by the health care team and the patient/family. Plans will contain specific self-management goals, objectives, and interventions with the patients that are action oriented. Identifies barriers and empowers patients/families to achieve maximum levels of wellness and self-management. Involves patient/family in the formation and ongoing evaluation of the plan of care.

4.

1. Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, barriers/ issues and goals. Monitors and evaluates the progress of the patient.

5. Schedule and coordinate appointments for patients needing medical care, mental health services and other specialty care.

6. Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, barriers/ issues and goals. Monitors and evaluates the progress of the patient.

7. Provide bene?t coordination including assistance in enrolling into state and federal bene?ts e.g., Medicaid

8. Completes accurate medication reconciliation identifying any discrepancies and collaborating with providers to resolve medications- related issues.

9. Administers vaccines ensuring proper documentation, patient education and adherence to safety and regulatory requirements.

10. Maintain accurate documentation of all interactions, care plans, and patient progress in the patient tracking system.

11. Work with correctional facilities, probation of?cers, and other community organizations to ensure seamless service coordination and care delivery.

12. Drive improvement of clinical quality measures- in partnership with the rest of the quality department

13. Performs and/or participates in other appropriate projects or duties as assigned this may include vaccine clinics, home visits or other off site nursing needs.

Supervisory Responsibilities

None

Core Competencies

· Customer Service: Committed to increasing customer satisfaction, sets proper customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met.

· Communication: Understand and communicate effectively with others using a variety of contexts and formats, which include writing, speaking, reading, listening and interpersonal skills.

· Dependability: Meets commitments, works independently, accepts accountability, handles change, sets personal standards, stays focused under pressure, meets attendance/punctuality requirements.

· Quality: Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems, owns/acts on quality problems.

· Productivity: Manages a fair workload, volunteers for additional work, prioritizes tasks, develops good work procedures, manages time well, and handles information flow.

Success Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Education/Experience

Graduate of an accredited School of Nursing.

Current, unrestricted Registered Nurse license in the state of Ohio.

Minimum of 3 years of nursing experience.

A minimum of 2 years of care management experience is required, preferably in a healthcare or social services setting. Experience working with individuals transitioning from the criminal justice system (e.g., jail or prison) or experience in behavioral health or substance use treatment strongly preferred.

Language Skills

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Computer Skills

To perform this job successfully, an individual should have the ability to gain knowledge of current practice management system, electronic medical record, Microsoft Word, text paging, Internet, and Intranet.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee is occasionally required to sit and stoop, kneel, crouch, or crawl. The employee must regularly lift and /or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee are occasionally exposed to fumes or airborne particles; toxic or caustic chemicals and risk of radiation. The noise level in the work environment is usually moderate.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.