Assessment Nurse Care Coordinator - Per Diem

Boston Health Care for the Homeless Program•Boston, MA

4d•$49 - $55•Hybrid

About The Position

BHCHP is seeking an RN who is interested in flexible weekday hours and working on a small, tight-knit team that provides care coordination services to clients enrolled in the BHCHP OneCare Program. The OneCare program is a state initiative to promote care coordination, continuity of care, and improved health outcomes for those clients under 65 who are eligible for both Medicare and Medicaid. In this role, you will mostly focus on performing Uniform Core Assessment (UCA) assessments and creating care plans customized to meet the needs of individual clients. UCA training is provided by Commonwealth Care Alliance (CCA)/CareSource. You will also help update these plans both annually and when a client has had a significant change in status. You will be required to provide face-to-face outreach to meet with clients, assess their status, and support the client’s progress toward better health outcomes. You will also connect with clients by phone, communicate with providers about client needs, and connect clients to eligible services including visiting nursing, nutrition, durable medical equipment, and social services. Clients may be housed; living in shelters or on the streets and you will need to be resourceful to connect with our clients. It is anticipated that success with connecting with clients will require communication with BHCHP care teams and shelter partners, use of BHCHP and CCA/CareSource electronic medical records, as well as outreach to clients who are living on the street, shelter, or in temporary or permanent housing. You will need to remain flexible and creative, as this role will continue to evolve as experience is gained. There is potential for this role to expand to full-time hours in the future if the candidate is interested.

Requirements

Licensed as RN in Commonwealth of Massachusetts.
Previous community health center or primary care experience.
1- 2 years RN experience preferred.
Demonstrated interest in public health, primary and preventive nursing and working with an under-served population.
Strong medical and surgical assessment skills.
Interest in working with disadvantaged groups; understanding of substance abuse and mental health.
Excellent organizational and interpersonal skills; timely and strong communication skills via phone, e-mail, and internal secured messaging systems.
Ability to work as part of a team and autonomously; must be able to work with and cooperate with multidisciplinary teams to achieve best patient care.
Ability to prioritize and have attention to timetables to complete tasks.
Experience with documenting in EMRs: EPIC, Guiding Care, and ECW strongly preferred.
Proficient with Microsoft Office Suite and ability to adapt to technological changes.
Must be well organized, efficient and can work autonomously and within a team.

Nice To Haves

Driver’s license a plus.

Responsibilities

Assumes responsibility for the coordination of care between BHCHP medical teams and the OneCare program for BHCHP clients who are enrolled in the OneCare Program.
Conducts UCA assessments for clients enrolled in the OneCare program; collaboratively participates as a member of the primary care team that includes M.D.s, N.P. /P.A. s, Clinical RNs, behavioral Health Clinicians, Medical Assistants, Case Managers and others.
Communicates with clients and/or caregivers including performing outreach as necessary in the greater Boston area for face-to- face contact to homes, hospitals, other facilities, etc. as needed to assess build relationships, client status, and identify new care needs; communicates clearly and professionally with other members of the interdisciplinary team as well as with clients and caregivers.
Uses CCA/CareSource and BHCHP’s Electronic Medical Records (EMR) in a timely manner to note all client interactions and outcomes accurately and efficiently; input authorizations for Durable Medical Equipment and other services (Home Health Aide, Skilled Nursing, Physical Therapy, and Personal Care Attendant) based on UCA assessment; bills for UCA assessments into BHCHP’s EMR (EPIC) weekly.
Conforms to BHCHP standards of performance around client rights, customer service, infection control, safety procedures and culturally competent care.
Remains flexible in duties as role expands and is available for assistance with other projects as needed.