* Supervises the Complex Chronic Care Management Team for the various insurance companies Patient Centered Medical Home Programs. The Complex Chronic Care Management Team works with patients and staff across the six PHMC health centers. * Gathers and organizes data and information needed for the different insurance companies based on their Patient Centered Medical Home Program. * Ensuring all identified patients are assessed appropriately and individualized care plan are initiated with the team which includes health conditions, treatments, behaviors, risks, support resources, values, preferences and overall needs to develop care plan then work with patient/caregiver/co-learner/providers to develop goals, informs care team if inappropriate for complex care and makes recommendations for care plan in usual care team. * Assesses patient readiness for transition back to health center care team or to more intensive level of care * Holds regular IDT meetings with complex care team, patient provider, RN care manager, BHC and any other appropriate staff member. * Ensures patient assessments, health education, health screenings, and other disease prevention programs are completed. * Serves as complex care manager for patients with complex chronic health problems as identified by the insurance companies and/or referred by a SHS provider. * Records care provided within electronic medical record and completes other assigned reports. * Works within all state and federal laws and regulations. * Notifies immediate supervisor of significant problems. * Maintains positive relationships with funding sources and community organizations. * Performs other tasks as directed and needed.
* Strong written and verbal communication skills * Ability to work with diverse staff in an urban setting * Current CPR certification Ability to maintain comprehensive, accurate and timely nursing documentation
* Four- year experience preferred in primary care, community health and/or behavioral health * Experience with homeless people, and a diverse population * Case management experience * Demonstrated abilities performing comprehensive nursing assessments