Triage and Care Coordination Nurse

firsthand is changing the way individuals living with Serious Mental Illness (SMI) get care – by putting them at the center of everything we do. Our peer led model aims to build trust with these individuals, many of whom have been underserved, stigmatized, deprioritized and have very often lost trust in the systems intended to serve them. Our holistic approach includes partnering with our team of peer recovery specialists, licensed social workers and nurse practitioners, and focuses on meeting them where they are and walking with them side by side, as a trusted guide, partner, and first call, on their journeys’ to wellness. 

Our aim is to not only improve lives, but also improve the economics for managed care plans and states responsible for providing care to this community. This enables us to build solutions that scale and, as a result, change the way our society supports those most impacted by SMI.

We are building a team of deeply passionate problem-solvers who are courageous enough to take on one of the country’s most challenging healthcare problems. Those who are up for the task will be rewarded with deeply mission-oriented workdays, mentorship from a similarly motivated team, and a supportive culture that prioritizes learning, creativity, and fun.

The Triage and Care Coordination Nurse (TCCN) is a remote nurse that provides telephone and electronic triage support to firsthand patients and staff, and supports outpatient care coordination. They work 8-10 hour shifts, currently working hours only, but with a likelihood to include evenings and weekends by the end of 2022. The TCCN work will enable fH team’s Health Guide, to focus on assessment, care coordination and disease management.

In each of firsthand’s Tennessee markets in Nashville, Memphis, Knoxville, Chattanooga, a Health Guide (HG, licensed Nurse Practitioner or Physician Assistant) leads the medical aspects of team-based care for individuals that firsthand serves. Health guides provide comprehensive assessment, care coordination, disease management, transitional care for persons not yet reengaged with ongoing primary care/BH care and occasional urgent care. Health guides do not provide ongoing full-service primary care or behavioral healthcare. They collaborate closely with external primary care and behavioral health providers, as well as an internal team of firsthand Guides (fHGs, peers mental health workers) and Community Resources Guides (CRGs, social workers).

This population traditionally has high rates of urgent issues, ED visits and inpatient admissions, as well as poor connectivity with ongoing outpatient care. To help our patient live better lives outside of the hospital, firsthand:

• Identifies and addresses medical and psychiatric concerns early, before they lead to poor health outcomes and avoidable healthcare utilization, and

• Strengthens connections between firsthand patients and longitudinal primary care, behavioral health, and medical specialty providers

TCCNs will be the first clinical point of contact for firsthand patients with urgent or acute concerns. They will primarily take phone calls and messages from fHGs, our frontline team of peer mental health workers, who are the primary relationship managers for our patients. They will attempt to address these urgent issues though a combination of:

• Collaborating with fHGs to assess and manage the issue independently, including through phone and video encounters with patients

• Urgently connecting patients with their outpatient care providers, including PCPs and CMHCs/outpatient behavioral health,or local urgent care and walk-in clinics as is determined most appropriate 

• Collaborating with HGs to manage the issues at hand, batching non-urgent issues like mediation refills to be managed asynchronously, and escalating true urgencies/emergencies immediately

The firsthand patient population has a high burden of both medical and behavioral health comorbidities, and issues will include a combination of medical and psychiatric complaints.

When not addressing acute issues during working hours, the TCCN will work with HGs and firsthand staff to telephonically and electronically coordinate care for firsthand patients.

As a Triage and Care Coordination Nurse you will:

• Work 16-24 hours a week on a remote basis
• Receive inbound clinical issues from firsthand staff and patients directly by phone and Slack message
• Collaborate closely with firsthand staff, including peer mental health workers, social workers, and APPs to address acute issues as early and comprehensively as possible
• Do phone and video encounters with firsthand patients
• Look up patient histories and document activities in the Canvas EHR
• Coordinate care with our patients’ other care providers
• Develop and deliver training on basic medical issues to peer mental health workers and social workers
• Other care planning and management activities

TCCNs will have two types of shifts - working hours shift and “on-call” shifts.

• Working hours shifts will be 8-10 hours, paid at an hourly rate of $40, and TCCNs are expected to be doing care coordination, training and related administrative work when not managing acute issues.
• On-call shifts will cover evenings, holidays and weekends. These will be paid at a rate of $15/hr for availability, plus $25 per patient care episode addressed. There are no expectations on this time other than immediate availability and the management of acute issues that arise

You will be a good fit if you have:

• Excellent clinical acumen in outpatient chronic disease and mental health care
• The ability to rapidly triage and prioritize patient issues, and identify the appropriate level of care
• Creativity and excellent problem solving skills, with a willingness to “think outside the box” to solve patient issues
• The ability to provide problem specific patient education and self-management suggestions
• Empathy, compassion, and approachability 
• Excellent listening, communication, and interpersonal skills
• Desire to help people in need and support their path to wellness
• Comfort working as part of a multidisciplinary team, and enjoy mixed roles and duties
• Cultural humility, knowledge of trauma informed care, and social determinants of health
• Desire to implement and deliver care that is integrated across chronic medical conditions, behavioral health conditions, inpatient settings, and outpatient settings
• Intermediate computer skills, familiarity with Microsoft Office Suite, Slack
• Ability to adapt rapidly to variations in team culture and process

The experience you bring to this role includes:

• RN/BSN with active TN licensure
• 5+ years clinical care experience including triage in Emergency Department and/or Primary Care settings
• Working with and managing a population with challenges such as behavioral health and/or SUD conditions
• Care management and coordination 

Compensation:

• firsthand is building a workplace and culture that cares deeply for our team and our communities. TCCNs will be 1099 contractors contracted on an hourly basis.

firsthand Benefits:

For Full Time employees, our compensation package includes base, equity and a bonus potential. Our benefits include physical and mental health, dental, vision, 401(k) with a match, 16 weeks parental leave for either parent, flexible vacation, and a supportive culture.

We firmly believe that great candidates for this role may not meet 100% of the criteria listed in this posting. We encourage you to apply anyway - we look forward to getting to know you.

Unfortunately, we are not able to offer sponsorship at this time.