Montgomery County Homeless Initiative Program
Nurse Case Manager
 

The Montgomery County Homeless Initiative Program (HIP) for the medically and psychiatrically vulnerable provides housing to 30 - 40 formerly homeless individuals including those who have been frequent users of the emergency medical systems, numerous hospitalization readmissions, correctional services and linked to numerous County resources.   These clients are housed in a permanent supportive housing program with case management services from a case worker and nurse.  The Nurse Case Manager will also provide backup coverage for our hospital discharge program, nursing assessments for clients in the program and street homeless and provide nursing clinical services to the street outreach team for medically vulnerable clients who are actively street homeless.  Services include: Intensive on-site case management; life skills training; assistance in acquiring a primary health care provider and accessing for mental health and drug treatment services; provide collaboration with other community providers to aid clients in obtaining benefits and entitlements, linkages to appropriate services available in the community including food, clothing, workforce development opportunities and psychiatric rehabilitation day program; participate in treatment team meeting; aid in crisis responses and  make referrals for additional supportive resources.
 

For more information please go to: www.primarycarecoalition.org and http://www.mcch.net/programs/chipp.html.
 
Job Description:

The Nurse Case Manager provides case management services to residents of the 30-40 Homeless Initiative Program (HIP) units located throughout Montgomery County.  These individuals are among those previously homeless County residents experiencing the most extreme medical and behavioral health issues. The Nurse Case Manager is the primary clinical liaison available to provide medical in-home services, advocacy and supportive resources to the clients.

 
Responsibilities include:

• Provide home-based RN assessment, triage, case management, medication monitoring, and patient education to all clients residing in the 25 HIP-supported units located throughout the County.
• Collaborate and coordinate the client's medical needs/issues with client's treatment team (case manager, medical and behavioral health providers, etc.)
• Assist clients as needed with managing their medications by filling medication boxes and coordinating refill of medications, etc.
• Conduct one-on-one health education training for HIP residents on an as-needed basis on medical topics that will assist the client in managing his/her medical conditions. 
• Meet with each client in his/her home at least once per month.  Separate monthly meetings with the case manager may also be scheduled.
• Collaborate on discharge planning with County staff to promote the safe and timely return of the client to his/her housing placement with adequate medical follow-up after a hospitalization. Obtain relevant medical records upon discharge to inform the client’s provider team.
• Assist clients in obtaining transportation to medical appointments by providing bus tokens, Smart Trip Cards, and/ or taxi cab vouchers made available through County resources. 
• Attend medical appointments as necessary for those clients that may need assistance in understanding and complying with provider instructions.
• Meet with case management staff on a regular basis to coordinate services to sustain stable housing for the client.
• Document each client contact in the client’s record within 24 hours.
• Keep a monthly updated sheet of visitation and any outstanding concerns for bi-weekly review/update with program supervisor.

To succeed you will need:

• Maryland licensure as Registered Nurse
• Professional liability coverage with a limit of liability of at least $1M per claim and $3M in aggregate. 
• 2+ years clinical experience—home health experience preferred
• Experience working with special populations (including low income)
• Experience working with complex medical cases
• Experience working with individuals with untreated mental illness and/or substance abuse disorders
• A current driver’s license, access to a vehicle for transportation and current automobile insurance
• Able and willing to travel to 30-40 HIP units; which are in scattered locations throughout the County
• Ability to perform multiple tasks, manage time effectively and have good problem solving skills
• Strong interpersonal skills; ability to establish working relationships with patients, families, co-workers, and community resources; ability to deal with difficult people
• Excellent communication skills—oral and written;
• Ability to deal sympathetically with a multi-cultural population;
• Knowledge of disease process and management;
• Demonstrated ability to be organized, focused, empathetic and work well under pressure;
• Excellent “eye for detail,” good follow up orientation, and self-motivation;
• Strong computer skills; including the Microsoft Office Suite and some experience with Electronic Medical Records;
• Knowledge of community resources;
• Bilingual English/Spanish preferred.

If our mission and job interest you, please submit your cover letter and resume. 

ADA Requirements

This job operates in a professional office environment.  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.

• This role routinely uses standard office equipment such as computers, telephones, photocopiers, filing cabinets and fax machines.
• This is largely a sedentary role; however, some filing may be required.
• This would require the ability to lift files, open filing cabinets and bend or stand as necessary. 
• Requires ability to learn new software applications as necessary.
• Must be able to lift up to 20 pounds. 
• Requires travel throughout Montgomery County. 

This job description indicates in general the nature and levels of work, knowledge, skills, abilities and other essential functions (as covered under the Americans with Disabilities Act) expected of an incumbent.  It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of an incumbent.  An incumbent may be asked to perform other duties as required.