Public Health Nurse
The primary responsibility of this position is to provide Care Management for High-Risk Pregnancies Program (CMHRP) services offered at the Onslow County Health Department. Performing intermediate professional work providing primary, preventive, and rehabilitative care for individuals and families in Public Health Programs, and related work as apparent or assigned. The CMHRP Program’s mission is to ensure that high-risk patients receive the best possible care. To ensure quality services are consistently delivered to the target population by adhering to expectations outlines in the Program Manual.
To perform this job successfully, an individual must be able to perform each essential function satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Position Responsibilities:Care Coordination:
- Refer potentially Medicaid-eligible pregnant patients for prenatal care and Medicaid eligibility determination, including promoting the use of Presumptive Eligibility determination and other strategies to facilitate early access to Medicaid coverage during pregnancy.
- Conduct outreach efforts in an attempt to engage patients identified as needing intensive care management services as having a priority risk factor by: the health plan risk stratification, provider request, hospital utilization (Admissions, Discharges and Transfers) through claims data (emergency department utilizations, antepartum hospitalization, utilization of labor and delivery triage unit) for referral to prenatal care and to engage in care Management.
Population Identification and Engagement
- Review and enter all pregnancy risk screenings received from Pregnancy Management Programs (PMPs) covered by the pregnancy care managers into the designated care management documentation system within five calendar days of receipt of risk screening forms.
- Utilize risk screening data, patient self-report information and provider referrals to develop strategies to meet the needs of those patients at highest risk for poor pregnancy outcome.
- Accept pregnancy care management referrals from non-PMP prenatal care providers, community referral sources (such as DSS or WIC programs), patient self-referrals, and provide appropriate assessment and follow up to those patients based on the level of need.
- Review available health plans data reports identifying additional pregnancy risk status data, including regular, routine use of the Obstetric Admission, Discharge and Transfer (OB ADT) report to the extent the OB ADT report remains available to local health departments.
- Collaborate with out-of-county PMPs and Care Management for High-Risk Pregnancy Program team members to facilitate cross-country partnerships to ensure coordination of care and appropriate care management assessment and services for all patients in the Target Population.
Assessment & Risk Stratification
- Conduct a prompt and thorough assessment for all patients deemed as “high risk” for adverse birth outcomes who may need intensive care management services.
- Utilize assessment findings, including those conducted by the health plans, to determine level of need for care management support.
- Ensure all assessment findings are documented in the care management documentation system.
- Ensure that assessment documentation is current throughout the period of time the CMHRP Care Manager is working with the patient and should be continually updated as new information is obtained and/or based upon program standards.
- Ensure engagement levels are assigned as outlined according to program guidelines, based on member need(s).
- Provide care management services in accordance with program guidelines, including condition-specific pathways, utilizing those interventions that are most effective in engaging member and meeting their needs by prioritizing face-to-face encounters (practice visits, home visits, hospital visits, community encounters); additionally, utilizing other interventions such as telephone outreach, video conferencing, professional encounters and other interventions as needed to achieve care plan goals.
- Provide care management services based upon member need(s) as determined through ongoing assessment.
- Develop patient-centered care plans, including appropriate goals, interventions and tasks based on standardized, statewide CMHRP programmatic guidance documents.
- Utilize the statewide resource platform and identify additional community resources.
- Refer identified population to prenatal care, childbirth education, oral health, behavioral health or other needed services included in the beneficiary’s health plan network.
- Document all care management activity in the care management documentation system.
Organizing and Directing:
- Integration with Health Plans and Health care Providers
- Establish a cooperative working relationship and mutually agreeable method of patient-specific and other ongoing communication with the PMP.
- Establish and maintain effective communication strategies with PMP providers and other key contacts within the practice for each PMP with the county of serving residents of the county.
- Ensure participation in relevant PMP meetings addressing care of patients in the Target Population as requested.
- Maintain awareness of in-network providers and assist health plan when accessing referrals and resources.
- Obtain information needed as it relates to the health plans’ prior authorization processes relevant to referrals.
Collaboration with Health Plans
- Work with health plans to ensure program goals as outlined in this document are met.
- Review and monitor health plans reports created for the PMP and CMHRP services to identify individuals at greatest risk.
- Communicate with the health plans regarding challenges with cooperation and collaboration with maternity care providers.
- Where care management is being provided by a health plan and/or AMH practice in addition to CMHRP, the health plans must ensure the delineation of non-overlapping roles and responsibilities.
- Participate in CMHRP and other relevant meetings hosted by the health plans as resources and time permits.
- Attend CMHRP training offered by the health plan(s) and/or DHHS, including webinars, New Hire Orientation or other programmatic training.
- Attend continuing education sessions coordinated by the health plan and/or DHHS.
- Pursue ongoing continuing education opportunities to stay current in evidence-based care management of pregnancy and postpartum women at risk for poor birth outcomes.
- Access to Motivational Interviewing, Mental Health First Aid and Trauma-Informed Care training.
- Demonstrate a high level of professionalism and possess appropriate skills needed to work effectively with the pregnant population at high risk for adverse birth outcomes.
- Demonstrate proficiency with the technologies required to perform care management functions.
- Demonstrate Motivational Interviewing Skills and knowledge of adult teaching and learning principles.
- Demonstrate ability to effectively communicate with families and providers.
- Demonstrate critical thinking skills, clinical judgement and problem-solving abilities.
- Comply with all expectations delineated in the Program Guide.
- Comply and submit monthly local statistics and reports to the CMHRP Supervisor to assist with continued program analysis.
- Discusses program strategic planning and interventions with CMHRP Supervisor.
Other Duties, as assigned:
- Attends workshops, seminars, and continuing education programs in order to update knowledge and skills.
- Performs other duties as may be assigned by competent authority. These duties may include responding to public health disease outbreaks and natural disasters.
- Qualifications:Knowledge of social work principles, techniques, and practices, and their application to complex casework, group work, and community problems.
- Knowledge of a wide range of medical, behavioral and psychosocial problems and their treatment.
- Knowledge of family and group dynamics and a range of intervention techniques.
- Knowledge of governmental and private organizations and resources in the community.
- Knowledge of the methods and principles of casework supervision and training.
- Knowledge of medical terminology, disease processes and their treatment as they relate to decisions regarding clinical interventions and appropriate therapies based on medical or psychological diagnosis.
- Skill in establishing rapport with a client and in applying techniques of assessing psychosocial, behavioral, and psychological aspects of client's problems.
- Ability to train or instruct lower-level social workers, students, or interns.
- Ability to establish and maintain effective working relationships with members of case load and their families as well as civic, legal, medical, social, and religious organizations.
- Ability to express ideas clearly and concisely and to plan and execute work effectively.
- Ability to make accurate observations of clients and families and to record and communicate this clearly;
- Ability to understand and follow oral and written instructions.
- Ability to deal tactfully with others, and to secure the cooperation of clients; to elicit needed information, and to maintain effective working relationships;
- Ability to accurately record services rendered, and to interpret and explain records, reports and medical instructions.
- Ability to work with others in the performance of these duties and assisting with other routine tasks of a reasonably high level of complexity.
Education, Experience, and Special Requirements:Special Requirements
A Registered Nurse (RN)—See Below and 2 years experience with client population.
Bachelor of Nursing (which includes a public health rotation) accredited by the National league for Nursing or the Commission on Collegiate Nursing and 1 year experience with the client population.
Additional Training/Experience: Current License from the North Carolina Board of Nursing to practice as a registered nurse in North Carolina Registered Nurses without a bachelor’s or master’s degree that included a public health rotation will be required to complete the “Introduction to Principles and Practices of Public Health Nursing” course within one year of employment in accordance with the Health Services Commission Rule.
Valid driver's license.
Salary will be determined based on qualification, internal equality, budget, and market consideration.
In order to be considered for this position, your final transcripts showing the data that your degree was awarded and/or any required certificates or licenses must be uploaded with your application even if you are current employee or we received it with a previous application