POSITION SUMMARY: As a member of the Interdisciplinary Care Team, the Nurse Case Manager is responsible for the coordination and implementation of health care services for each individual residing in Elwyn New Jersey's community living program sites and enhanced behavior homes. The nurse provides clinical and consultative services and educates the team about consumer-specific needs. The nurse also liaisons with external providers to facilitate care coordination and ensures that established standards of care are met.

The nurse practices within the scope of New Jersey Board of Nursing laws and in accordance with Elwyn New Jersey's policies and procedures and those of Elwyn New Jersey's regulatory agencies.

DUTIES AND RESPONSIBILITIES:

• Review ongoing medical, dental, and psychiatric treatment with the treatment team to ensure recommendations are addressed in a timely manner
• Assist in identifying health care needs and provide site staff with individual training that focuses on general health conditions, treatments, and interventions specific to each individual's health needs and consistent with standards of care
• Review all Medical Appointment Forms, lab data, and diagnostic test results with the Treatment Team
• Provide continuity of care through timely follow up with physicians and other health care providers to ensure that agency and licensure requirements are met
• Monitor individuals' weights and vital signs on a monthly basis and more frequently as needed; identify changes from baseline and report abnormal findings to the Primary Care Physician and Treatment Team.
• Summarize Medical Appointment Forms, telephone contacts, and ongoing health care follow up in the nursing progress notes
• Monitor consumer immunization status and ensure that each consumer remains up to date and current (as per NJ State regulatory guidelines)
• Monitor consumers for potential safety risks and the need for adaptive equipment, monitor all adaptive equipment to ensure that it remains in good working order and facilitate repair/replacement when equipment issues are identified
• Complete a monthly review of medication boxes and Medications Administration Records for each site. Provide a written report summarizing any issues or discrepancies to the Nurse Practitioner, Program Director, Quality Improvement Specialist, and others as designated by the Supervising Nurse Practitioner
• Complete a general review of each residence on a monthly basis to validate that privacy, safety, infection control and general standards are met. Documents monthly exams into the electronic medical records as applicable
• Provide coordination of clinical services between Elwyn New Jersey's CLP/EBSP and hospitals, physicians, pharmacies, and other community-based providers and services
• When a consumer is admitted into a hospital, skilled nursing facility, or rehab center:
  • Collaborate with the facility's staff to ensure appropriate care and maintain active involvement in discharge planning throughout the consumer's stay
  • Oversee the consumer's transition back Elwyn New Jersey by reviewing discharge recommendations, ensuring that medication/equipment is available, and providing staff training related to ongoing care and treatment needs
  • Monitor ongoing medical/safety needs during the transition back to Elwyn
• Obtain and review all reports from all inpatient stays, Emergency Department visits, diagnostic procedures, and specialty appointments coordinating follow up health care needs as indicated
• Provide nursing-on-call coverage as required during evening and weekend hours, which may include travel to specific homes if the presence of an RN is needed to help resolve the presenting issue, completing on call progress notes, documenting in the site nursing note, and forwarding to administration and the treatment team to ensure timely communication
• Participate in meetings, committees, and seminars to ensure that nursing practice remains current with emerging trends in the care of individuals with Intellectual Disabilities (ID) and Developmental Disabilities (DD)
• Complete all annual mandatory educational requirements as assigned by Elwyn within the designated timeframe
• Perform cardiopulmonary resuscitation (CPR), safety care techniques, and medication administration using agency-trained protocols
• Maintains current state-mandated training and certifications
• Follows all current policies and procedures of Elwyn New Jersey
• Cooperates with Elwyn New Jersey and the State of New Jersey Department of Human Services, or any other authorized investigating body during an inspection or investigation
• Perform other duties as assigned

IMMEDIATE SUPERVISOR: Nurse Practitioner

DIRECT REPORTS: None

CONTACTS: Elwyn consumers, personnel, families/guardians, physicians and other health care providers, BCBAs and service agencies such as pharmacies, hospitals, skilled nursing facilities, and hospice program personnel

EDUCATION/EXPERIENCE/SKILLS REQUIREMENTS:

• Graduate of an accredited nursing program
• Licensed Registered Nurse (RN) in the State of New Jersey
• One (1) year general nursing or medical surgical experience
• One (1) year of Developmental Disabilities nursing experience
• Excellent planning, communication, customer interaction, collaboration, and documentation skills required
• Current CPR certification
• Demonstrated ability to work effectively as part of a team
• Must be able to perform CPR and safety care techniques using agency-trained protocols
• Experience using/knowledge of Electronic Health Record (EHR) / Electronic Medical Record (EMR)
• Demonstrated intermediate experience with Microsoft Office applications, including Word, Excel and Outlook
• Demonstrated ability to work effectively as part of a team
• Ability to work in a fast-paced environment and manage and prioritize multiple, often competing, priorities
• Demonstrated strong attention to detail
• Demonstrated strong time management and organizational skills
• Demonstrated excellent judgment with the ability to independently solve problems and make decisions with little or no need for direct supervision
• Demonstrated ability to anticipate future needed changes or identify problem areas and take effective actions
• Must possess excellent customer interaction, collaboration, presentation, and written and verbal communication skills
• Must have current, valid driver's license in state of residence, 3 years driving experience in the United States, and acceptable driving record

PHYSICAL DEMANDS/ENVIRONMENTAL PROFILE: See Physical Demands Checklist below which represents the general physical demands and environment conditions to which the employee holding this position must meet, in addition to the duties and responsibilities listed above, to successfully perform the essential functions of this job. Elwyn New Jersey will engage otherwise qualified candidates for this position whose disabilities may require reasonable accommodations to enable an individual to perform the essential functions.

Elwyn New Jersey reserves the right to revise or change job duties and responsibilities as needed. This job description is not intended to be an all-inclusive statement of duties and responsibilities of the job nor does it constitute a written or implied contract.

Elwyn New Jersey is an Equal Opportunity Employer. Elwyn does not discriminate on the basis of race, color, religion, creed, ancestry, pregnancy status, medical condition, gender, gender identity or expression, genetic information, sexual orientation or identity, age, national origin, citizenship, handicap status, marital or family status, mental or physical disability, perceived disability, military or veteran status, political activities or affiliations, or any other characteristic protected under applicable federal, state or local law, ordinance, or regulation.