Primary Care Coalition has an open position for a Bilingual Community Health Nurse (CHN) to support the organization’s ability to offer behavioral and somatic health services to underserved patients living in Montgomery County. This position is for those who are interested in applying their behavioral health care skills to make healthcare more accessible for those who need it most. As a Bilingual Community Health Nurse, you will be part of a team that is working to advance health equity for vulnerable patients, many who experience challenging life experiences and hardships while establishing themselves in the United States.  

The Bilingual CHN will support the healthcare and wellness needs of low-income, immigrant patient populations with chronic mental health diagnoses who are receiving care at the Montgomery County’s Department of Health and Human Services’ (DHHS’) Adult Behavioral Health Program (ABHP). The CHN partners with psychiatric prescribers to deliver, manage and orchestrate care to patients who have healthcare needs. In this role, the CHN also supports patients’ connection to primary care, helping patients address chronic conditions, such as diabetes and hypertension, that may be outside of their mental health diagnosis.   The CHN partners with patients to educate them and support them in implementing healthy behaviors shown to manage and/or improve their conditions. Fluency in both Spanish and English is essential.  

This role is perfect for someone who has strong clinical expertise and enjoys working on and coordinating care with an interdisciplinary team consisting of case managers, therapists, and psychiatric prescribers.  

The ideal candidate will possess excellent interpersonal skills and a demonstrated ability to work well with a diverse range of people. The CHN must be flexible and able to problem solving with patients and providers. The candidate will need to work effectively as a member of an interdisciplinary team, display good clinical judgment and decision-making skills, and possess excellent communication skills, both written and verbal.    

You are a great fit if you are passionate about public health, supporting vulnerable communities, and have experience working with immigrant populations with primary care and mental health needs. The role requires you to have a commitment to diversity, equity, and inclusion and a passion for advancing health equity. This job is best performed by someone who has an open and flexible mindset and is eager to contribute and learn.   

Within PCC, the CHN reports to the PCC Director of Behavioral Health, and the day-to-day work is overseen by the Supervisory Therapist at DHHS’ ABHP. The CHN serves as an interprofessional team member at Montgomery County DHHS ABHP and operates under the medical direction of that department's prescribers.  The CHN’s work also allows the therapists at ABH to decrease time spent on medical related tasks. 

Bilingual in English and Spanish required. Must have reliable transportation and be available to work evenings on Mondays and Wednesday until about 8pm. 

Telework 

This position is approved to telework one day week (cannot be a Monday or a Wednesday).  Staff member must be physically onsite at the clinic 4 days a week as well as occasional meetings at the PCC Headquarters office in Silver Spring, Md.  The job duties require in-person meetings and time on-site at the ABHP office to meet with patients as well as to foster strong collaborative relationships and consultation with ABHP and PCC colleagues.  Relocation costs will not be provided.

Essential Duties 

1) Perform and accurately document clinical services with clients in an integrated setting  

• Provide and document evidence-based nursing care to clients under CHN care; involving patients’ family if possible; the scope of care includes conducting intakes with new patients, assessments,, providing treatment and referrals, documenting and responding to reported symptoms, client complaints, lab work, vital signs, nutritional needs, and other relevant data in the electronic health record.
• Establish a schedule for collection of vital signs and lab work to monitor side effects of psychotropic medications and detect or prevent onset of chronic medical conditions and communicate with laboratories regarding lab results; request labs; and coordinate with prescribers on lab results when indicated for assigned panel of patients. 
• Communicate with pharmacies to problem-solve administrative, payment, or other challenges related to prescriptions generated by psychiatric prescribers.
• Monitor clients’ behavior and specific outcomes to evaluate the effectiveness and need to change or maintain health education strategies on issues such as weight loss and smoking cessation to prevent onset of common chronic disease processes such as diabetes and hypertension.
• Administer injectable medications prescribed by staff prescribers.
• Develop and conduct weekly health education groups in English and/or Spanish on such issues as nutrition, smoking cessation and exercise.
• Complete training on County-personnel practices and procedures, and program-specific policies, procedures and systems.   

2) Lead Care coordination for patients requiring care with external providers of ABHP with external providers  

• Coordinate care between ABHP's prescribers and client’s primary care provider, share relevant health information and as appropriate coordinate the provision of health care services.
• Connect patients to dental clinics.
• Serve as main liaison between PCC’s safety net Behavioral Health Program and ABHP, coordinating activities, facilitating communication and making referrals between the programs.
• Scan and review all documents related to medical records from primary providers and specialists, hospitals, labs, pharmacies, and pharmacy assistance programs; highlighting any concerns to discuss with prescribers 

3.) Partner with pharmaceutical organizations and insurers to cover patients’ essential healthcare coverage and medications 

• Initiate and collaborate with PCC’s medication assistance program, the DHHS Pharmacy, and pharmaceutical representatives to ensure patients have access to the psychotropic medications they need.
• Develop and maintain collaborative working relationships with insurance case managers to facilitate healthcare coverage for patients.
• Maintain a working knowledge of payer coverage policies to advocate on behalf of client with third parties for cost-effective high-quality services and best use of resources.
• Coordinate pharmaceutical representative visits for the clinic to facilitate training on new medications for clients with a chronic mental illness.
• Maintain and manage medication and medical supply inventory.

Skills and Abilities 

• Ability to work independently 
• Utilizes a patient-centered approach to partner with patients to improve their health outcomes 
• Possesses strong clinical decision-making, incorporating client’s needs and preferences to arrive at recommended medical interventions  
• Strong collaboration skills and comfort with working with other prescribers, primary care physicians, behavioral health therapists and other healthcare professionals to coordinate care 
• Ability to build strong rapport and work effectively with patients, families, co-workers, medical providers, and leaders and staff from other community-based programs 
• Strong verbal and written communication skills  
• Strong organizational skills, attention to detail, and follow-up 
• Proficiency in Microsoft Word and the ability to learn and use an electronic medical record and other software programs and cloud-based systems 
• A flexible and open mindset 

Education and Experience  

• Current/unexpired license as a registered nurse in the state of Maryland Required.
• Minimum two years’ experience as a Registered Nurse and experience working with adults with psychiatric disorders 
• Experience working with low-income immigrant adults, multidisciplinary professionals, and providing services in an outpatient setting preferred 
• Bilingual, English and Spanish (Advanced Proficiency Required) 

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, storage rooms and fax machines 
• This is primarily a sedentary role; however, some movement of material goods may be required 
• This would require the ability to lift files, open filing cabinets or storage areas and bend or stand as necessary 
• Requires ability to learn new software applications as necessary 
• Must be able to lift up to 20 pounds 
• Must be able to travel locally 

Disclaimer  

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. 

 Primary Care Coalition is an Equal Opportunity Employer.