Integrated Care Nurse (Outpatient & Full-Service Partnership)

Job Description

Job Description

Description:

Position Summary:

The Integrated Care Nurse (Outpatient & Full-Service Partnership) is a full-time member of the multidisciplinary behavioral health team, providing nursing services, psychiatry and medication support, health education, care coordination, and integrated healthcare interventions across the Agency's Outpatient Clinical Services (OCS), Child & Youth Wellbeing (CYWB), and Full-Service Partnership (FSP) programs. The position supports children, adolescents, adults, and families experiencing behavioral health conditions, serious mental illness (SMI), co-occurring substance use disorders, emotional and behavioral challenges, and complex needs.

Working collaboratively with the psychiatrist, therapists, case managers, family partners, peer support staff, care coordinators, and community providers, the nurse promotes whole-person wellness through integrated behavioral health and physical healthcare services. The position combines clinic-based and community-based nursing functions to improve treatment engagement, medication adherence, health outcomes, continuity of care, and access to medical and behavioral health services. Services may be provided in office, community, home, school, telehealth, and other approved service settings based on client and program needs.

Key Responsibilities

1.Integrated Care & Team-Based Support

• Participate as an active member of multidisciplinary treatment teams, providing nursing expertise related to physical health, medication management, and wellness.
• Collaborate with psychiatrists, therapists, case managers, family partners, peer specialists, care coordinators, and community providers to support integrated, client-centered care.
• Contribute a health and medication-focused perspective to assessments, treatment planning, case consultations, and ongoing care coordination.
• Provide services in office, home, school, community, and other approved settings, as clinically indicated and consistent with program needs.
• Support engagement and outreach strategies for high-acuity, difficult-to-engage clients, particularly those experiencing serious mental illness, co-occurring disorders, or significant barriers to care.
• Participate in team meetings, treatment reviews, and case conferences.
• Promote collaborative, trauma-informed, recovery-oriented, and culturally responsive care.

2. Medication Support, Medication Administration, Monitoring and Coordination

• Doctor Day Management- Coordinate aspects of “doctor day”, ensuring proper scheduling and follow-up, with support from the program assistant. Assist clients in accessing visits and telehealth, and accompany clients in the sessions as needed.
• Administer prescribed injectable medications in clinic, office-based, and community settings in accordance with provider orders and scope of practice.
• Assist clients and families in understanding prescribed psychiatric and medical medications, including intended benefits, potential side effects, risks, and adherence strategies.
• Monitor clients for medication effectiveness, adverse reactions, side effects, and changes in functioning, and communicate concerns promptly to prescribing providers and treatment team members.
• Conduct medication reconciliation activities with clients and communicate medication-related concerns to treatment team members and prescribing providers.
• Support medication adherence through education, reminders, problem-solving barriers to treatment, and individualized interventions.
• Coordinate with psychiatrists, medical providers, pharmacies, and other treatment team members regarding prescription access, refills, prior authorizations, medication-related concerns, and continuity of care.
• Assist clients with medication organization, prescription refill coordination, and pill-box setup or supervision, as clinically indicated and within scope of practice.

3. Health Assessment & Monitoring (Within Scope)

• Conduct nursing assessments, screenings, observations, and vital sign monitoring within scope of practice.
• Monitor physical health conditions and identify changes requiring referral or intervention.
• Assess and support management of chronic medical conditions, including diabetes, hypertension, asthma, obesity, and other health concerns.
• Support preventative healthcare and wellness activities.
• Identify health-related barriers that may impact treatment participation and overall wellness.
• Coordinate appropriate referrals for medical evaluation, labs, and treatment when indicated.

4. Child, Youth & Family Support Services

• Provide developmentally appropriate health education and support to children, adolescents, and their caregivers, as needed.
• Collaborate with caregivers regarding treatment recommendations, medication education, and healthcare needs.
• Coordinate care with primary care, schools, specialty providers, and community resources, as appropriate and authorized.
• Support family engagement as an essential component of treatment and recovery.
• Assist in identifying physical, developmental, and healthcare concerns affecting emotional well-being and treatment outcomes.

5. Full-Service Partnership (FSP) & Community-Based Services

• Provide field-based nursing and care coordination services to FSP clients as clinically indicated.
• Support engagement of individuals experiencing serious mental illness, co-occurring substance use disorders, and complex psychosocial needs.
• Assist with outreach and engagement efforts for difficult-to-engage clients.
• Support transitions from hospitals, residential treatment programs, crisis settings, and other higher levels of care.
• Coordinate healthcare services that promote community stability, recovery, independent living, and overall wellness.
• Participate in intensive community-based service delivery consistent with FSP program expectations

6. Behavioral Health & Substance Use Integration

• Support integrated treatment approaches for mental health and co-occurring substance use disorders.
• Reinforce recovery-oriented and harm-reduction principles.
• Assist clients in accessing substance use treatment and recovery support services.
• Coordinate with providers regarding Medication for Addiction Treatment (MAT), withdrawal management, detoxification, residential treatment, and recovery resources when appropriate.
• Support client engagement in behavioral health and substance use treatment services.

7. Care Coordination & System Navigation

• Coordinate and collaborate with:
• Primary care providers
• Specialty medical providers
• Pharmacies
• Hospitals and emergency departments
• Substance use treatment providers
• Other service partners

Responsibilities include:

• Facilitating communication among providers and treatment team members.
• Coordinating referrals and linkage to healthcare and community resources.
• Supporting continuity of care following hospitalization, emergency department visits, and other transitions.
• Assisting clients and families in accessing healthcare services and benefits.
• Advocating for access to appropriate medical and behavioral health treatment.

8. Crisis Intervention & Clinical Support

• Participate in crisis response and assessment activities within scope of practice.
• Support clients experiencing psychiatric, substance use-related, or medical crises.
• Collaborate with the treatment team regarding safety planning and level-of-care decisions.
• Assist with coordination of emergency evaluations, hospitalization, and follow-up care when appropriate.
• Support stabilization and continuity of care following crisis events.

9. Client & Family Education

Provide education related to:

• Psychiatric medications
• Medical conditions and chronic disease management
• Health literacy
• Nutrition and healthy lifestyle practices
• Wellness and prevention
• Substance use and recovery
• Medication adherence
• Community healthcare resources
• Self-management and independent living skill

Support clients and families in developing knowledge and skills that promote wellness, recovery, resilience, and independence.

10. Documentation & Compliance

• Complete timely, accurate, and thorough documentation of all services provided.
• Maintain documentation in accordance with Department of Health Care Services (DHCS), Los Angeles County Department of Mental Health (LACDMH), Medi-Cal, licensing, and Agency requirements.
• Document health assessments, medication administration, care coordination activities, client contacts, and clinical interventions within required timelines.
• Always maintain confidentiality and compliance with HIPAA, State and Federal laws, and organizational policies.
• Participate in quality improvement, utilization review, and compliance activities as required.

Minimum Qualifications

• Current and unrestricted California license as one of the following:
• Registered Nurse (RN) preferred
• Licensed Vocational Nurse (LVN)
• Licensed Psychiatric Technician (LPT)
• Experience working with children, adolescents, adults, or families in behavioral health, healthcare, community mental health, social services, integrated care, or related settings.
• Knowledge of behavioral health conditions, psychotropic medications, and person-centered care practices.
• Ability to work effectively as part of a multidisciplinary team.
• Valid California Driver's License, reliable transportation, and ability to travel throughout assigned service areas. Ability to drive Agency vehicles.
• Ability to meet Agency insurance and background clearance requirements.

Preferred Qualifications

• Experience in community mental health, outpatient behavioral health, Full-Service Partnership (FSP), Assertive Community Treatment (ACT), Intensive Case Management (ICM), or integrated care settings.
• Experience working with children, youth, adults, and families.
• Experience administering long-acting injectable medications.
• Familiarity with LACDMH programs, Medi-Cal behavioral health services, and documentation standards.
• Knowledge of trauma-informed care, recovery-oriented practices, family-centered care, and harm reduction approaches.
• Bilingual abilities are strongly preferred.

Core Competencies

• Strong engagement and relationship-building skills.
• Commitment to person-centered, trauma-informed, culturally responsive care.
• Ability to collaborate effectively within a multidisciplinary team environment.
• Strong organizational, documentation, and time-management skills.
• Ability to adapt to changing client and program needs.
• Effective communication and problem-solving abilities.
• Comfort working in both office-based and community-based service settings.
• Ability to independently prioritize responsibilities while maintaining high-quality service delivery.

Work Schedule

• Full-Time: 40 Hours per Week
• Schedule may include occasional evening hours, community visits, and flexible scheduling based on client, program, and Agency needs.