Hybrid Chronic Care RN, Care Manager

at Charles River Community Health

• Job title: Chronic Care RN, Care Manager
• Job type: Full Time
• Experience level: Mid level, Senior
• Salary: $35 - $45 per hour
• Degree requirement: Bachelor's Degree
• Location requirements: Hybrid, Brighton, United States

About the role

• Chronic Care RN (Care Manager) at Charles River Community Health integrating care for complex conditions and populations. Balancing on-site and remote outreach for effective patient management.

Responsibilities

• Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with primary care providers.
• Meet the patient where he/she is; observe the patient without intervention or judgment.
• Has knowledge of common chronic medical conditions presented in the population served and is able to: Educate the patient on their medication conditions and medications, and build their self-management skills; Use motivational interviewing to promote behavioral change.
• Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.
• Conduct medication reconciliation in conjunction with the clinical pharmacist.
• Engage members and caregivers in active care planning with a focus on medical, behavioral, social, member-centered care needs.
• Coach and guide member/representative to meet bio/psycho/social goals.
• Provide care coordination, which may include but is not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up.
• Delegate assignments to Community Health Workers and/or Patient Navigators or Social Workers, follow up on completion, and be consistently available for timely consult regarding patient matters during business hours.
• Meet regularly with medical directors and nurse care managers, and speak as needed with Primary Care, ED, and inpatient to triage program issues appropriately when patients are discharged from hospitals.
• Participate in local site operations, including team meetings.
• Actively participate in planning and growth of the program as needed, to respond to evolving needs of Mass Health ACO.
• Maximize the use of ACO care management tools and technology to ensure that work is comprehensive, detailed, automated and streamlined to the extent possible.
• Make recommendations to change workflows to enhance the ease of use, practicality, and effectiveness of the ACO tools and processes.
• Understand the relationship between work done in the ACO's system and the work done in EHR.
• Ensure that workflows are optimized to recognize and support both the ACO's system and EHR.
• Facilitate interdisciplinary consultation on patient's behalf through participation in rounds, team meetings, and clinical reviews.
• Establish and comply with quality metrics for performance and adhere to documentation and work flow standards.
• Maintain HIPAA standards and confidentiality of protected health information.
• Adhere to departmental/organizational policies and procedures.
• Provide assistance in seasonal influenza/COVID vaccination efforts when applicable.
• Participate in the integrated care team meetings and rounds as required.
• Maintain accurate, timely documentation in electronic systems including health center EHRs.
• Provide coverage for team members who are out of office.
• Serve as the point person for enrollees coming out of the Transitions in Care Program and moving into CCM.
• Take all needed steps that this process is seamless for care team members and the enrollee, family, and caregivers.
• Ensure that all care management is offered in a culturally and linguistically-appropriate manner and with disability competence.
• Ensure that all necessary accommodations are consistently made for members with disabilities.
• Promote a sense of teamwork through demonstration of self-direction and self-motivation.
• Solve problems independently or know when to seek consultation.
• When onsite, co-locate near the medical nursing and provider teams for teambuilding.
• Perform other duties as assigned by the Lead Chronic Care Nurse or designee.

Requirements

• Bachelor of Science degree in nursing required.
• Must be licensed in Massachusetts as a Registered Nurse
• Experience in nursing with recent clinical experience in outpatient medical setting or other related outpatient practice preferred.
• Must have demonstrated solid interpersonal, communication, and management skills.
• Must be able to continually update clinical knowledge and skills through formal and informal education and review of current literature.
• Must have knowledge of ambulatory and clinical practices, workflows, and operations.
• Must work well independently, have sound decision making skills, and work effectively with and through inter-professional colleagues when required to make and facilitate complex decisions.
• Must exercise a high degree of professional judgment within the scope of licensure.
• Experience working with historically underserved populations preferred.
• Bilingual (Spanish, Portuguese, or Haitian Creole) strongly preferred.
• Experience with Patient Centered Medical Home model and concepts preferred.
• Must have a willingness to work flexible hours to meet the organization's needs/demands.
• Must be able to travel to either Charles River Community Health site (Brighton and Waltham) as needed.

Benefits

• Medical & Dental Insurance
• Short & Long-term Disability Insurance
• Generous Paid Time Off
• Flexible Spending Account
• Employee Assistance Program
• Tickets at Work
• Health Reimbursement Arrangement
• Travel Reimbursement
• Professional Development Opportunities