UHS·Madera County, California
Conduct comprehensive nursing and nutrition assessments for new admissions while coordinating the intake process with families, payors, and medical staff. Manage the initial multidisciplinary treatment plans and ensure compliance with medication reconciliation and discharge documentation.
Conduct and document the complete Nursing Assessment, including an admission summary and nutrition assessment (not to exceed 48hrs). Identify, document and prioritize mental/medical problems, including the need for detoxification as appropriate. Initiate the Initial Multidisciplinary Treatment Plan, noting Initial Diagnosis, Psychiatric/Psychosocial problem (minimum of 1) and obtain patient’s signature if applicable. Inventory Patient’s Home Medication with patient’s signature and notify House Supervisor to retrieve for patient lock-up until discharged. Initiate Close Observation (CO) forms. Responsible for the timely processing of inquiry and referral calls. Responsible for coordination of all admissions processes and serves as liaison to referral sources, families, payors, physicians, unit and hospital personnel involved with each admission. Respond to crisis calls and referrals with sense of urgency, verify insurance, triage patients, complete assessments, ability to staff clinical effectively, enter calls and admissions in computer and complete all admission paperwork with patient. Effectively communicate with unit staff and assist patient to unit. Pre-cert with payor source. Follow hospital’s policies and procedures regarding admissions. Responsible in maintaining compliance on the following: Medication reconciliation Patient’s charts Patient's Medical Treatment Plan Patient's discharge documentation Customers Served Patients, families, medical staff, allied health professionals, other hospital department staff and external individuals requesting information.
Education: Graduate from an accredited program of professional nursing required; Bachelor's Degree preferred.
1-3 years of experience preferred in psychiatric health care. Working knowledge of DSM-V diagnostic criteria, mental status exam, and addiction and recovery field.
Currently licensed to practice by the California State Board of Nursing.
Additional
Requirements: CPR certification and successful completion of Crisis Prevention Intervention (CPI) training. CPI Training may be obtained during new hire orientation.
Excellent communication skills, i.e., verbal and written. Ability to prioritize duties as to need and urgency; work well under periods of high stress and pressure. Ability to multi-task and demonstrate critical thinking skills. Demonstrates an understanding of funding entities. Thorough knowledge of psychiatric services provided by the hospital. Ability to work flexible hours. Requires a basic understanding of computers; and accurate data entry skills. Knowledge of insurance contracts and payors. Knowledge of precertification for inpatient hospitalization. Experience gathering and documenting medical and clinical information to assess and staff appropriately with physician. Ability to triage for medical and psychiatric needs. Working knowledge of DSM-V diagnostic criteria, mental status exam, and addiction and recovery field.
Exposure to psychiatric patients who may exhibit violent/aggressive behavior. Potential for exposure to communicable diseases; blood/body fluids; and other hazardous waste. General hospital and office environment.
Specific Standards for the Care of Child Patients Ages 5 through 11 1.
Maintain knowledge of the Child Program rules, protocols and handbooks guidelines.
2.
Maintain knowledge of children’s stages of development and seek guidance from the nurse in charge when questions about the norms for behavior related to child development arise.
3.
Assess patients for behaviors consistent with the developmental stages and make note of any deviations in behavior.
4.
Recognize acting out behavior of child specific age group and set appropriate limits in clear, concise, behavioral and non-judgmental terms based on the age of the patient.
5.
Demonstrate an awareness of learning disabilities and translates treatment/program expectations to the learning-disabled child.
6.
Relate to child patients in an age-appropriate manner.
7.
Utilize seclusion and restraint procedures with an understanding of the need for modification in regard to smaller body sizes of children, abandonment issues and the history of physical and/or sexual abuse issues.
8.
Act as a resource to other staff in regard to the Child Patient Programs.
Specific Standards for the Care of Adolescent Patients Ages 12 through 18 1.
Maintain knowledge of the Adolescent Program rules, protocols and handbooks guidelines.
2.
Assess patients for behaviors consistent with the developmental stages and makes note of any deviations in behavior.
3.
Recognize acting out behavior of adolescent specific age group and set appropriate limits in clear, concise, behavioral and non-judgmental terms based on the age of the patient.
4.
Demonstrate an awareness of learning disabilities and translates treatment/program expectations to the learning-disabled adolescent.
5.
Relate to adolescent patients in an age-appropriate manner.
6.
Utilize seclusion and restraint procedures with an understanding of the need for modification in regard to smaller body sizes of adolescents, abandonment issues and the history of physical and/or sexual abuse issues.
7.
Act as a resource to other staff in regard to the Adolescent Patient Programs.
Specific Standards for the Care of Adult Patients Ages 19 through 64 1.
Gather information from the patient, family and interdisciplinary team and use judgements based on knowledge of adult behaviors in treatment planning and interventions.
2.
Recognize behaviors and set appropriate limits in clear, concise, behaviors and non-judgmental terms.
3.
Utilize seclusion/restraint procedures applicable to adult body size and past history of violent or emotional behaviors and/or history of physical and/or sexual abuse issues.
4.
Maintain current knowledge of the Adult Program rules, protocols and handbook guidelines.
5.
Utilize theoretical concepts to guide the effective practice of adult care within Specific Standards of Care for this age group.
Specific Standards for the Care of Geriatric Patients Ages 65 and older 1.
Maintain knowledge of the developmental tasks and sociological theories of aging.
2.
Utilize theoretical concepts to guide the effective practice of gerontological health care and behavioral care.
3.
Gather the appropriate information from the patient, family and interdisciplinary team and use therapeutic judgements based on knowledge of gerontological health/behavioral care practices to develop a comprehensive plan of care.
4.
Utilize interventions based on gerontological theory to restore patients’ functional capabilities and to prevent complications and excess disability.
5.
Maintain a complete knowledge of treatments, medications and side effects of such in the geriatric age group.
Specific Standards for the Care of Chemically Dependent Patients 1.
Assesses patient needs as related to chemical dependency and document the plan of care from the admission through discharge.
2.
Collaborate with other chemical dependency staff professionals in planning for discharge and follow-up care.
3.
Maintain an awareness of how personal issues relating to co-dependency can impact work performance/relationships.
4.
Recognize and establish limits on medication-seeking behaviors.
Hours based on departmental and facility needs may include day, evening and weekend hours. This job description in no way states or implies that these are the only duties to be performed by this employee. The employee will be required to follow any other instructions and to perform any other duties as requested by the ACNO
Requires a professional nursing degree and a valid California State Board of Nursing license, with a Bachelor's degree and 1-3 years of psychiatric experience preferred. Must hold CPR certification and complete Crisis Prevention Intervention (CPI) training.
Market context
In California, behavioral-health roles tied to substance use disorder counseling and case management are typically supported by ongoing community and treatment-program demand. These positions are competitive because employers often look for a high school diploma, at least 2 years of SUD counseling or case management experience, and current Registered or Certified Drug and Alcohol Counselor status. Review the AI-summarized requirements and benefits here to quickly compare fit and note that professional development and paid continuing education are listed as benefits.