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, Waltham, United States

About the role

• Nurse Care Manager focusing on care management for patients with chronic conditions. Working in a hybrid model to support health outcomes in underserved communities.

Responsibilities

• Champion Patient Success: Serve as the dedicated Care Manager for a patient panel
• Bring Goals to Life: Update and maintain holistic care plans that reflect the 'whole person'
• Lead Care Integration: Facilitate high-level care coordination, connecting patients with the right resources
• Identify and recruit appropriate patients for care management from lists and referrals
• 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
• Conduct medication reconciliation in conjunction with the clinical pharmacist
• Engage members and caregivers in active care planning
• Provide care coordination, which may include facilitating care transitions
• Meet regularly with medical directors and nurse care managers
• Participate in local site operations, including team meetings
• Maximize the use of ACO care management tools and technology
• Ensure that workflows are optimized to recognize and support both the ACO's system and EHR
• Maintain HIPAA standards and confidentiality of protected health information
• Provide assistance in seasonal influenza/COVID vaccination efforts when applicable
• Maintain accurate, timely documentation in electronic systems
• Serve as the point person for enrollees coming out of the Transitions in Care Program

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.
• Must have excellent communication skills, particularly with people from diverse cultures whose primary language is not English, with the ability to understand the community, population, and patients we serve.
• Must believe in the work we do at CRCH, with a strong passion to serve underserved populations in diverse settings.

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