Duplin County NC

Public Health Nurse II – Care Management for At Risk Children

DEPARTMENT:  Duplin County Health Department                                                                                                        

SALARY:  “Based on Nursing Education Degree and Public Health Nursing Experience”

OPENING DATE: December 2, 2019           “OPEN UNTIL FILLED” 

APPLY AT:  Duplin County Personnel Office
                      County Administration Building
                      224 Seminary Street
                      Kenansville, NC  28349                                                                                                                   

                      “Equal Opportunity Employer”


The primary purpose of this position is to serve as the Care Management for At-Risk Children (CMARC) case manager to provide individual and family needs assessments, case management, educational and counseling intervention and community referrals for high-risk children and families. This work includes families with complex economic, social and medical issues such as child abuse and neglect, parental mental illness, parental substance abuse, HIV infection, and homelessness. This employee serves as a resource and liaison to other medical providers and agencies. 



This list of essential functions, as outlined herein, is intended to be representative of the tasks performed within this classification. It is not necessarily descriptive of any one position in the class. The omission of an essential function does not preclude management from assigning duties not listed herein if such functions are a logical assignment to the position.

93%        Care Management for At-Risk Children

  • Responsible to educate patients, medical homes and community organizations on the benefits of the program.
  • Contact patients identified as having a priority risk factor through claims data analysis or through the CMARC Referral Form.
  • Identify community resources available to meet the specific needs of the population (resource manual).
  • Uses data summaries and reports created by NCCCN, Inc. to identify those individuals at greatest risk.
  • Utilize the CMARC Referral Form, provider referrals, and children identified through claims data analysis as high cost/high users of services to develop strategies to meet the needs of those children at highest risk for poor outcomes.
  • Utilize information entered into Virtual Health, Case Management Information System, such as care plans and assessments and to identify children needing additional interventions.
  • Complete and enter into Virtual Health assessments and care plans on all children receiving care coordination.
  • Includes the following elements in the assessment: family status and home environment; medical/behavioral/dental health status; social supports; financial needs; family demands, relationships, and functioning (Life Skills Progression); cultural beliefs and values; strengths/assets of child, family caregivers; and current goals for the child and family.
  • Care plans will include goals and expected outcomes.
  • Uses risk stratification to determine the services needed.
  • Document family progress using the Life Skills Progression instrument.
  • Establish processes to support the case coordination of those in the identified population, based upon risk stratification guidelines.
  • Provide care coordination services in accordance with the care plan and service pathways utilizing those interventions that are most effective in engaging patients and meeting their needs, including telephone outreach, practice encounters, home visits, and/or other interventions needed to achieve care plan goals.
  • Provide care coordination services based upon level of need as determined through the assessment and care planning process.
  • Develop patient-centered care plans and document all activities within Virtual Health.
  • Identify local community resources available to meet the specific needs of the population.
  • Refer identified population to relevant education, oral health, behavioral health or other needed services reimbursed by Medicaid.
  • Refer target high risk population to relevant community resources.
  • Refer clients to evidence-based parenting programs and other services as appropriate.
  • Work with medical homes to assure smooth transitions among and across care settings as needed (e.g. hospital to community) and to develop action oriented care plans as appropriate (including self-management skill building).
  • Assess and follow-up on compliance with needed clinical services and developmental screenings.
  • Ensure changes in status and compliance with care are communicated to the medical home/PCP and other appropriate providers.
  • Provide education about the importance of and assistance with the scheduling of PCP visits and having a medical home.
  • Review and monitor reports created for the CMARC program to determine individuals at greatest risk and opportunities for quality improvement.
  • Communicate with local network regarding challenges with cooperation and collaboration with PCP and non-PCP related services.
  • Attend CMARC and Virtual Health trainings offered by the Division of Public Health and NCCCN, Inc.

5%          Clinic

  • Participates in direct patient care of clients receiving services in the Health Department clinic including adult health services, child health services, STD services, immunizations, communicable diseases and tuberculosis control.
  • Assesses client’s needs in General Clinic.
  • Maintains knowledge of immunizations, physical assessment, TB skin testing and treatment, STD treatments and communicable disease.
  • Provides and documents appropriately child health limited history.
  • Obtains patient history and work-up of Child Health patient for FNP.
  • Maintains knowledge of HIV control measures to prevent spread of HIV within the community.
  • Documents in EMR system.


2%          Other

  • Serves as a team member during outreach projects such as flu vaccine season, disease outbreaks, disaster shelters and other duties as directed by supervisor and attends related meetings as assigned by supervisor.


  • Graduation from a four-year college or university with a BS Degree in Nursing which includes a Public Health Nursing rotation and one year of Public Health Nursing experience; or Graduation from an accredited school of professional nursing and two years of professional nursing experience including one year in public health; or An equivalent combination of education and experience


Must be or become certified in basic CPR life support
Reliable means of transportation for work assignments
Current and active NC Registered Nursing License
Valid, current NC driver’s license
Two years experience working with children and their families
Introduction to Principles and Practices of Public Health