Behavioral Health - RN Care Partner

Marana Health is seeking an RN Care Partner to join our Behavioral Health Team at the Counseling & Wellness Center, located in the heart of Marana, AZ. The RN Care Partner is responsible for providing coordination of services to patients and their families across the continuum of care. The RN Care Partner assesses, plans, implements, coordinates and evaluates the plan of care in partnership with the patient/family and other members of the healthcare team.

Marana Health is a Federally Qualified Community Health Center (FQHC), with 11 sites in Tucson and Pima County. Marana Health is building a world‑class integrated health care system that is committed to caring for special populations, and focused on improving health outcomes for our patients.

• Associate Degree in Nursing
• Valid Arizona State License as a Registered Nurse
• 2 years’ nursing experience
• Basic Life Support certification (BLS)
• Fingerprint Clearance Card through the Arizona Department of Public Safety (or ability to obtain upon hire)

• Case Management experience
• Bilingual (English/Spanish)
• Certified Diabetes Educator (CDE from NCBDE) or Board Certified‑Advanced Diabetes Management (BC‑ADM from AADE) credential

Equivalent combination of education and experience may be considered if applicable and must be directly related to the functions and body of knowledge required to successfully perform the job.

• No supervisor responsibility for this position.

• Demonstrated competencies in dealing with all age groups including neonates, infants, children, adolescents, adults, and geriatric patients.
• Applied knowledge of computer applications in a Windows based environment.
• Applied skill in patient triage in a primary care setting.
• Knowledge of patient appointment scheduling.

• Demonstrates effective behaviors as outlined in the organization-wide core competencies.
• Assesses, plans, implements, coordinates and evaluates the plan of care in partnership with the patient/family and other members of the health care team.
• Guides transition of care for ongoing planning to achieve individualized patient/family quality outcomes.
• Evaluates patient/family outcomes continuously updating the care plan.
• Serves as patient advocate serving as a liaison between patient, family, and healthcare provider.
• Documents care plan and interventions.
• Ensures patient-centered coordination within the medical home with team-oriented outcomes designed to facilitate the provision of comprehensive health promotion and chronic condition care.
• Ensures a focus of ongoing, proactive, planned care interventions to support illness management and relapse prevention.
• Assists to improve measures.
• Monitors and sustain quality outcomes.
• Clinical, functional satisfaction, and cost.
• Assists with or promotes the identification of patients in the practice with special health care requirements.
• Initiates patient/family contacts.
• Creates ongoing processes for families to determine and request the level of case management support desired for the patient/family member at any given point in time.
• Builds care relationships among patient, family, and care team.
• Supports the primary care‑giving role of the family.
• Develops care plan with patient and/or family members.
• Emergency plan, medical summary and action plan as appropriate;
  Carries out care plan.
• Evaluates and monitors effectiveness of plan and affects change as required;
  Educates, counsels and supports.
• Provides developmentally appropriate preventive guidance to facilitate referrals appropriately.
• Cultivates and supports primary care and subspecialty co‑management with timely communication, inquiry, follow up, and integration of information into the care plan.
• Serves as medical home quality improvement team consultant.
• Assists in measuring quality to identify, assess, refine, and implement practice improvements for patient‑center care.
• Works from standing orders from providers.
• Works with providers to reduce documentation on provider desktops as per protocol guidance by CMO.
• Has scheduled appointments…