Substance Use Disorders Registered Nurse Case Manager

Position Title:    Substance Use Disorders Registered Nurse Case Manager
Department:    Nursing 
Supervisor:    Director of Nursing
Hours per week:    Full-Time/40 hours
    
Primary Function:
The Substance Use Disorders (SUD) RN Case Manager acts upon the order of Primary Care Providers to conduct intake assessments, patient monitoring, tracking, and ongoing support to patients with substance use disorders and chronic pain management issues. The SUD RN Case Manager ensures patients’ adequate linkages with behavioral health counseling, other levels of substance use care, including medication assisted treatment, and chronic pain management care. 

The (SUD) RN Case Manager carries out functions under the supervision of the Director of Nursing and overall guidance and consultation with the Medical Director. 
 
Duties & Responsibilities:
    •    Receive and maintain a log of all patient referrals from PCPs and evaluate and screen potential patients to engage in Medication Assisted Treatment.
•    Conduct intake assessments including: medical history, medication history, drug and alcohol history including treatment and current use, lab work (including LFT’s), urine toxicology screen, PPD, education on program, referral to methadone maintenance when appropriate, medication assisted treatment, counseling and psych.
•    In collaboration with patient and a multidisciplinary team, develop an individualized treatment plan based on patient’s needs assessment, consents and contracts.
•    Make patient referrals to behavioral health, and human services providers at the Health Center for needed services such as primary care and other substance use and mental health care.
•    Make “warm handoffs” and coordinate support to needed services at external organizations including hospitals, substance use treatment programs, etc.

•    Coordinate induction, stabilization, and maintenance of MAT when appropriate per clinic protocols under the licensure and direction of the prescribing provider and assess for side effects or other interactions.
•    Provide on-going nursing visits, educate patient about MAT and medication treatment side effects, interactions, safety, administration, and plan of care.
•    Document patients’ progress in the electronic health records adhering to state and federal regulations and requirements specific to MAT. 
•    Monitor and track patients including progress in their treatment plan and update PCPs and submit monthly reports.
•    Provide consult support to staff as needed on new and current patients in treatment. 
•    Engage with health center staff as part of the team and provide support, education and assistance to them in caring for patients with substance use disorders and chronic pain issues. 
•    Maintain ongoing communication with primary care provider/team with appropriate documentation and follow up.
•    Lead multi-disciplinary care coordination team meetings to discuss patients’ progress and need for additional support and follow up.
•    Communicate with outside agencies with ongoing plan of care of patient and support as needed with appropriate consents. 

•    Follow-up with new, non-compliant and lost to follow up patients to ensure continuity of care.

•    Participate as a member of the OD2A project and conduct the following:
o    Engage and screen patients into substance use navigation services with a focus on the four OD2A project priority groups [Black, Latinx, Homeless and individuals reentering the community after incarceration].
o    Facilitate activities for UCC patients focused on overdose prevention, decreasing stigma and increasing access to care.
o    Disburse OD prevention supplies and Rescue kits for patients in MAT and primary care.
o    Complete in a timely manner all data collection required by the OD2A project.
o    Participate in OD2A project required trainings and meetings.
 

Minimum Basic Knowledge:    

•    Good knowledge of common computer programs and use with an EHR or willingness to learn.  
•    Experience or a desire to work in a multicultural communi