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Indiana University Health Registered Nurse - Population /Care Coordination: Depression, Opioid Use Disorders and Other Conditions in Indianapolis, Indiana


Registered Nurse - Population /Care Coordination: Depression, Opioid Use Disorders and Other Conditions


We are seeking a registered nurse (RN) with a solid foundation in behavioral health or addictions to be a member of primary care teams to help implement and evaluate a new centralized collaborative care program for depression, opioid use disorder (OUD), and commonly co-occurring conditions (e.g., anxiety, chronic pain, insomnia) into primary care.

This RN position works collaboratively as a member of primary care teams to deliver high quality health care to patients with OUD and symptoms of depression. The RN in this position will have accountability for a designated population of primary care patients, centrally coordinate care with patients’ primary care team as well as other care providers (e.g., Mental Health), assist in meeting care needs of patients receiving medication-assisted treatment for OUD (e.g. buprenorphine/naloxone and naltrexone). The nurse will collaborate with a multidisciplinary team of Behavioral Health Consultants in developing treatment recommendations for patients with depression and opioid use disorder at IU Health Clinics. The RN provides a variety of nursing services primarily by phone, and secure messaging, utilizing nursing care processes, clinical and research protocols, and leadership skills to address the patient needs.

The RN functions in a self-directed role with a high degree of autonomy. The RN will have training and mentoring from an outside team of national expert RNs as part of a grant-funded project. Limited travel may be required for trainings; occasional travel to IU Health clinics to meet face-to-face with primary care teams will be required. The RN will be responsible for outreach to newly identified patients randomized to a study arm. Together with another RN later, they will be responsible for enrolling 200 participants into the CC arm of the trial, as well as delivery of the MI.CARE CC program to those enrolled participants. The CNMs will participate in weekly case management conferences led by expert Psychiatrist .

Essential functions of this role will include:

  • Performs initial assessment and intake obtaining social, medical, mental health, OUD and other substance use disorders and medication history, and provides follow up care via telemedicine platform or by phone when needed, proactively, including assistance scheduling clinical visits.

  • Reviews intake assessments, first with the Behavioral Health Consultants and then with the primary care team - including review of patients' condition, readiness, appropriateness for having OUD treated in primary care, and to establish appropriate plan of care for each patient.

  • Consistently uses clear and concise and effective written/oral communication with diverse constituents (patients, primary care providers, other team members, and in communication documented in the electronic health record).

  • Provides ongoing education and counseling (grounded in motivational interviewing and behavioral activation) regarding depression medications and symptom management, and proactive support of patients and coordination of services, facilitating referral to Mental Health and Wellness or other specialty programs as needed.

  • Provides ongoing education, counseling regarding OUD medications and relapse prevention, and proactive support of patients and coordination of services, facilitating in-home induction of buprenorphine and referral to specialty addictions treatment programs as needed.

  • Maintains a case management system and completes appropriate documentation with excellent record keeping complying with departmental policies and for program monitoring and federal reporting.

  • Outreaches national expert RN as needed for clinical support of patients with OUD

  • Provides weekly reports to the team of Behavioral Health Consultants for case review, discussion and the development of treatment recommendations or changes to the treatment plan

  • Confirm specimens collected per protocol (such as urine drug screens, HIV); evaluates and takes clinical actions per protocol

  • Establish strong relationships with clinicians and other health care team members. Works with primary care team members, waivered prescribers, integrated behavioral health clinicians, Mental Health and Wellness clinic(s) in helping patients access behavioral health support, and other communication, as needed

  • Assist in phone triage including prescription refills as needed, follow up of test results, critical values and medical issues

  • Willing to approach treatment of depression with evidence-based therapies and medications;

  • Willing to approach treatment of OUD with evidence-based medications, and to approach all patients with addiction with positive and respectful attitudes, modeling these qualities for others on the primary care team;

    *These RNs will be a central resource and not located in particular primary care clinics. They will be part of multiple healthcare teams, partnering with primary care providers and nursing staff, and integrated behavioral health clinicians, including the standard team RN (which does not change), and also works with patients to facilitate management of their depression, OUD and other conditions.

    The ideal candidate will have a strong background in behavioral health or addictions care, ability to demonstrate evidence-based practice and an interest and experience in coaching and population management.



    Minimum Education Requirements: Graduate of an accredited RN program.

    Preferred Education: Bachelors of Science in Nursing


    Minimum Experience Requirements: TBD

    Preferred Experience: Behavioral health or addiction nursing, proficiency with documentation in electronic medical records, and competency in written and oral communication skills. Experience working with patients with substance use disorders.


    Minimum License/Certifications Requirements: At time of hire Current Indiana State RN license.

    Preferred: N/A

    REQNUMBER: 303566