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Time Type: Full time
Department: South End Washington Primary Care
All Locations: 1601 Washington Street, 400 Shawmut Avenue
Description: $10,000 sign on bonus for new full-time RNs! (prorated for part-time and per-diem)
As an integral member of the care team, the Registered Nurse (RN) Care Manager (CM), Complex Care will collaborate with providers, nurses, therapists, care navigators, community health workers and other healthcare professionals to provide comprehensive care coordination. The CM will work in conjunction with the staff members and providers of the SE Primary Care team to provide direct outreach, support and offer ongoing assistance to the South End population. The CM will serve as an advocate for patients and families, helping them to navigate the healthcare system and access to necessary services and resources. The RN Care Manager will have the opportunity to make a profound impact on the lives of people living with complex, prenatal or pediatric conditions; many of whom also face multiple barriers in their lives. This position requires flexibility and may vary from day-to-day
Essential Duties & Responsibilities

• Tracking for all perinatal patients on a specific list of tasks
• Ensure the patients attend all their perinatal appointments, using a report. Collaborate with the clerical team in the rescheduling of appointments if patient no shows.
• Engages members and care givers in active care planning with focus on medical, behavioral, social, member-centered care needs. Coaches and guides member/representative to meet bio/psycho/social goals.
• Provide care coordination, which may include but not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow up.
• May be required to meet patients during in person provider visits as requested.
• Provide care coordination, pediatric support
• Assesses the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support including symptom response plans based on the member’s needs and preferences.
• Connects members with primary care, behavioral health, flexible services, Community Partner, respite, and other community based social services as indicated and appropriate
• Provides patients and families with the latest list of local community resources and support services [hard copy or provide web-based link] made available by the Community Health Workers and Pediatric Wellness Departments of the Health Center.
• Participates in the integrated care team meetings and rounds as required
• Maintain accurate, timely documentation in electronic systems including health center EHRs.
• Work with the quality department as it relates to follow up on the departments high risk patients.
• Responsible for running and maintaining high risk patient lists / reports.
• Be fully accountable for the completion of work within established timeframes and for achieving the goals established for the enrollee/family.
• Ensure that all care management is offered in a culturally and linguistically appropriate manner and with disability competence.
• Ensure that all needed accommodations are consistently made for members with disabilities.
• Utilize the ACO care management tools and technology to ensure that work is comprehensive, detailed, automated and streamlined, where appropriate.
• Use information about data trends for self-directed learning and performance improvement.
• Maintain excellent punctuality and attendance.
• Promote a sense of “team work” through demonstration of
• self-direction and self-motivation.
• Solve problems independently or knows when to seek consultation.
• Adheres to all EBNHC and departmental policies and procedures.
• Participate in required departmental activities and meetings.

QUALIFICATIONS:

• Education: Bachelor’s degree in nursing.
• Valid Massachusetts RN license

EXPERIENCE:

• 2-6 years of nursing experience, preferably with some combination of ambulatory care, community public health, case management or home health work experience
• Experience working with a Medicaid population is strongly preferred.
• Experience working with a Federally Qualified Health Cener is strongly preferred.
• Case Management Certification (CCM, ANCC RN-BC) preferred.
• Experience with diverse populations, and/or lived experience is highly preferred.
• Experience maternal and child health preferred.
• Bilingual preferred

SKILLS/ABILITIES:

• Strong written and verbal communication skills
• Experience with Microsoft Office programs: Excel, PowerPoint, Outlook
• Experience with Electronic Medical Record systems such as EPIC, preferred.
• Aptitude for learning new information technology platforms.
• Strong organization and attention to detail skills
• Strong analytical and problem-solving skills.
• Excellent interpersonal skills required, to provide guidance to patients and families.
• Ability to positively influence others with respect and compassion.
• Excellence in providing care to diverse populations.
• Resourceful, self-motivated, ability to prioritize.
• Ability to work as part of a multidisciplinary team including communicating and working with Providers, Social Workers, Community Health Workers, and other member of the health care team.
• Must be flexible and adaptable to change.

Benefits:

• MEDICAL, DENTAL, AND VISION COVERAGE
• LIFE AND DISABILITY INSURANCE
• 401(K) RETIREMENT PLAN
• TUITION REIMBURSEMENT
• FLEXIBLE SPENDING AND TRANSPORTATION ACCOUNTS
• PAID HOLIDAYS, VACATIONS, SICK, AND PERSONAL TIME
• GENEROUS STAFF DEVELOPMENT BENEFIT
• EXCELLENT MALPRACTICE COVERAGE
• PET INSURANCE
• FREE PARKING
• MBTA BENEFIT
• AND MUCH MORE