POSITION STATEMENT: The Lead Nurse (LN) provides medical expertise to the multidisciplinary teams responsible for the delivery of effective services to the individuals served to promote their health and wellness. The Lead Nurse is an effective member of the team with experience in providing a variety of health and wellness services to persons with behavioral health and substance use disorders, including development of comprehensive assessments and treatment plans, delivery of a wide range of clinical and supportive services, and working collaboratively with the treatment team and other service providers, including DSAMH. The Lead Nurse utilizes evidenced-based practices, including Motivational Enhancement Therapy, Trauma-Informed Care, and medication assisted treatment, to effectively intervene and support individuals served.
Direct Duties:
- Manages the facilitation of health care service needs of individuals served and ensures that these service needs are addressed.
- Confirms that all required medical assessments pursuant to best practices, contractual obligations, and licensure requirements are completed.
- Ensures that an individual's health care services adhere to the best practice, licensure requirements, and are consistent with the policies, procedures, and protocols of contractors and payers of services.
- Oversees effective wellness and medical services in accordance with policies and procedures; state and federal regulations; and extant professional, ethical, and legal principles.
- Provides leadership in developing and implementing wellness and health practices for individuals served to improve their overall wellbeing.
- Models a commitment to the mission of the organization.
- Maintains an effective therapeutic alliance with individuals served.
- Directs medical care coordination activities and meetings.
- Completes all required documentation, audits, reviews, and reports in a timely manner relative to current and ongoing health care service needs.
- Communicates and coordinates with individuals receiving services, healthcare providers, family members or legal guardians, and staff regarding individuals' health care needs.
- Utilizes the required Electronic Health Record to record, document, and monitor all health care encounters and interactions.
- Oversees the utilization of the organization's Electronic Health Record (EHR) at the site ensuring staff complete required documentation in accordance with policies and procedures and using the EHR's reporting capabilities to monitor productivity and compliance.
- Oversees and consults with staff to improve health outcomes and living environments for persons served.
- Provides training to staff, including Limited Lay Administration of Medications, basic medical care, nutrition, disease management, hygiene, etc.
- Abides by state and federal regulations, policies, and procedures related to confidentiality, patients' rights (PM 46), and exposure and infection control.
- Participates in performance improvement activities to evaluate and resolve problems related to risk management, utilization review, care outcomes, and quality assurance, including reviews of medication errors.
- Facilitates communication with Performance Improvement, Licensure, and Accreditations and funders regarding any errors and corrective action activities.
- Promotes effective working relations as part of the clinical team to facilitate the program's ability to meet its goals and objectives.
- Creates and maintains an environment which fosters group decision-making and treatment planning whereby each member is accountable for group decisions.
- Supports and models the use of evidence-based practices in the services provided, including trauma-informed care, motivational enhancement therapy, and relapse prevention.
- Works in close collaboration with the Director and other senior staff to ensure that the program meets its clinical and administrative objectives.
- Demonstrates respect and regard for the dignity of all clients, families, guests, fellow employees, and other collaborators to ensure a professional, responsible, and courteous environment.
- Collaborates effectively with internal and external referral sources and providers, including primary care providers, specialists, hospitals, and pharmacies to maximize the effectiveness of medical interventions and services.
- Serves as the primary liaison with the consulting dietitian and ensures that therapeutic diet orders are carried out.
- Attends and participates in required meetings and trainings, including the monthly Nursing Best Practice meeting.
- Provides regular feedback to staff consistent with the Continuous Training process.
- Coordinates and provides after-hours on-call support to program staff.
- Performs other duties as requested or assigned, verbally or in writing.
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