Chronic Care RN (Care Manager)

Charles River Community Health•Waltham, MA

1d•$35 - $45•Hybrid

About The Position

The mission of Charles River Community Health (CRCH) is to partner with individuals and families so they can thrive and lead healthier lives by delivering the comprehensive, integrated, and equitable primary healthcare that matters most to them. As an integral member of the chronic care management (CCM) team, the Chronic Care RN (Care Manager) 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 make it difficult for them to achieve the self-care required to improve their health and well-being. The ideal Chronic Care RN (Care Manager) candidate is someone who will be able to: Champion Patient Success: Serve as the dedicated Care Manager for a patient panel, building long-term, trusting relationships to drive better health outcomes. Bring Goals to Life: Update and maintain holistic care plans that reflect the "whole person," ensuring medical strategies align with what matters most to each individual. Lead Care Integration: Facilitate high-level care coordination, connecting patients with the right resources both within CRCH and across the broader healthcare landscape. 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 telephone or in-person in a variety of settings, including the health center, community, home, or an inpatient facility.

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 have experience working with diverse cultures.
Must believe in the work we do at CRCH, with a strong passion to serve underserved populations in diverse settings.

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.