RN Care Manager

Job Summary:

As an integral member of the care management team the Registered Nurse (RN) Care Manager (CM) will have the opportunity to make a profound impact on the lives of people living with complex and/ or chronic conditions, many of whom also face multiple barriers in their lives which makes it difficult for them to achieve the self-care required to improve their health and well-being. This position requires flexibility and may vary from day-to-day to meet members where they are. Outreach methods may vary based on the needs of the organization and may include telephonic or in person in a variety of potential settings such as but not limited to, the *health center, community, home, or an inpatient facility.

Responsibilities:

· Conducts Comprehensive Assessments

· Assures that medication reconciliation is complete. The RN CM will complete the medication reconciliation and may include a pharmacist and/or primary care team.

· 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 members while they are inpatient to provide education and support about the discharge process and transition members into care management.

· 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.

· In collaboration with Community Health Workers, creates and maintains a comprehensive inventory of local community resources through a web-based application, improving accessibility for members and providers, and linking members with the appropriate support services.

· Participates in the integrated care team meetings and rounds as required

· Maintain accurate, timely documentation in electronic systems including health center EHRs.

· Provides coverage for team members who are out of office

· Other duties as assigned Desired Skills:

· Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Pharmacists, Social Workers, Community Health Workers, and other health care teams.

· Ability to flexibly utilize clinical expertise to solve complex problems

· Experience working with patients with chronic and behavioral health needs

· Must be flexible and adaptable to change.

· Demonstrate the ability to work independently

· Must demonstrate excellent interpersonal communication skills

· Additional qualities that would be a good fit for our team include: Enthusiasm and passion for helping patients, genuine spirit, kind, and empathetic nature, and one who embraces a ‘go with the flow’ mentality

· Experience using appropriate technology, such as computers, for work-based communication

· Experience and proficiency with Microsoft Office and online record keeping Qualifications:

· Experience working with Federally Qualified Health Centers is strongly preferred

· Associate degree in Nursing; Bachelor’s Degree in Nursing preferred

· Current, active MA Registered Nurse license

· Case Management Certification (CCM, ANCC RN-BC) preferred

· 3-5 years of nursing experience, preferably in-home health, ambulatory care, community public health, case management, coordinating care across multiple settings and with multiple providers

$500 bonus at 6 months in role

$1,000 bonus at 1 year in role

Job Type: Full-time

Pay: $85,000.00 - $95,000.00 per year

Benefits:

• 403(b)
• 403(b) matching
• Continuing education credits
• Dental insurance
• Health insurance
• Health savings account
• Life insurance
• Paid sick time
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• Monday to Friday

Work Location: In person

Salary : $85,000 - $95,000