Re-Entry RN Care Manager

Our Mission

We meet people where they are and partner with them on their journey towards wellness.

We meet people where they are and partner with them on their journey towards wellness.

The destination for servant leaders to provide comprehensive and exceptional care.

• R – Respect
• I – Innovation
• S – Stewardship
• E – Excellence

The Re-Entry RN Care Manager serves in a dual-role supporting jail re‑entry coordination for justice‑involved patients and integrated care with a partner behavioral health practice. This role is responsible for facilitating safe, timely transitions of care, reducing gaps in medical and behavioral health services, and improving health outcomes for high‑risk populations through comprehensive nursing care management, care coordination, patient education, and interdisciplinary collaboration.

This job description reflects management’s assignment of essential functions. Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

• Facilitate care coordination for patients transitioning from jail or other community institutions, ensuring they are linked to primary care services immediately upon release.
• Complete intake assessments for individuals leaving jail to identify their medical, mental health, and social needs.
• Formulate and implement a care management plan that addresses the patient’s identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; educating the patient/family on the choices available. Establish a care management plan that is mutually agreed upon by the health care team and the patient/family. Plans will contain specific self‑management goals, objectives, and interventions with the patients that are action oriented.
  
  Identify barriers and empower patients/families to achieve maximum levels of wellness and self‑management. Involve patient/family in the formation and ongoing evaluation of the plan of care.
• Evaluate the effectiveness of the plan in meeting established care goals; revise the plan as needed to reflect changing needs, barriers/issues and goals. Monitor and evaluate the progress of the patient.
• Schedule and coordinate appointments for patients needing medical care, mental health services and other specialty care.
• Provide benefit coordination including assistance in enrolling into state and federal benefits e.g., Medicaid.
• Complete accurate medication reconciliation identifying any discrepancies and collaborating with providers to resolve medication‑related issues.
• Administer vaccines ensuring proper documentation, patient education and adherence to safety and regulatory requirements.
• Maintain accurate documentation of all interactions, care plans, and patient progress in the patient tracking system.
• Work with correctional facilities, probation officers, and other community organizations to ensure seamless service coordination and care delivery.
• Drive improvement of clinical quality measures— in partnership with the rest of the quality department.
• Perform and/or participate in other appropriate projects or duties as assigned; this may include vaccine clinics, home visits or other off‑site nursing needs.

None

• Customer Service:
  Committed to increasing customer satisfaction, sets proper customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met.
• Communication:
  Understands and communicates effectively with others using a variety of contexts and formats, which include writing, speaking, reading, listening and interpersonal skills.
• Dependability:
  Meets commitments, works independently, accepts accountability, handles change, sets personal standards, stays focused under pressure, meets attendance/punctuality requirements.
• Quality:
  Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems, owns/acts on…