Hybrid Nurse Care Manager

at Charles River Community Health

• Job title: Nurse 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

• Nurse Care Manager serving a patient panel with chronic conditions at Charles River Community Health. Building relationships to promote health outcomes and providing care coordination in a hybrid setting.

Responsibilities

• Serve as the dedicated Care Manager for a patient panel, building long-term, trusting relationships to drive better health outcomes.
• Update and maintain holistic care plans that reflect the "whole person," ensuring medical strategies align with what matters most to each individual.
• Facilitate high-level care coordination, connecting patients with the right resources both within CRCH and across the broader healthcare landscape.
• 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.
• 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.
• Ensure that all care management is offered in a culturally and linguistically-appropriate manner and with disability competence.

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.
• 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