Clinical Care Manager (RN)

Vinfen•Somerville, MA

5d•$90,000 - $90,000

About The Position

The Clinical Care Manager (CCM) provides care coordination and clinical management for One Care enrollees with complex healthcare needs. The Clinical Care Manager collaborates with Vinfen’s ACCS teams and the One Care Plan’s clinical staff to maximize coordination and integration of care. The CCM will be at the helm of organizing and coordinating resources and services in response to the individual healthcare needs across multiple settings.

Requirements

Strong knowledge base in clinical and financial aspects of care
Strong commitment to the right and ability of people served by Vinfen to live, work, have meaningful relationships, and receive the resources and supports needed in their community of choice
Knowledge of person-centered, strengths-based, recovery-oriented values and principles, and modalities
Knowledge of clinical and psychiatric rehabilitation values, principles, and techniques
Knowledge of health risks of psychiatric disability
Knowledge of health promotion and medical care coordination techniques
Knowledge of motivational interviewing, stage of change, and harm reduction techniques
Knowledge of trauma-informed and culturally competent services
Sensitivity to the cultural, religious, ethnic, disability, and gender issues
Skills and competence to establish supportive trusting relationships with program clients
Knowledge of human, legal, civil rights, community, and other resources
Knowledge of empowerment and self-advocacy techniques
Knowledge of teaching modalities
Knowledge of available community health and mental health services and resources
Knowledge and use of different communication and learning styles and supervisory techniques
Knowledge of formal and informal assessment practices
Knowledge of data-driven decision-making processes and ability to encourage others to use data analysis, as needed
Ability to triage/balance competing priorities
Ability to make independent judgments and decisions
Ability to work in a professional and confidential capacity
Ability to work independently as well as part of a multi-disciplinary team
Knowledge of personal computer applications and equipment
Knowledge of documentation standards requirements
Minimum of 5 years clinical and case management experienced preferred.
Effective skills in managing, teaching, negotiating, and collaborating with multidisciplinary teams and client/family focus.
Experience developing care plans.
Strong clinical and medical/surgical skills.
Strong organizational and time management skills.
Excellent written and oral communication skills.
Effective relationship management and team building skills.
Driving is a requirement for this position using either a Vinfen van or personal vehicle. - If using a personal vehicle, you must possess and maintain adequate insurance as well as maintain a safe driving record which is subject to annual checks. A valid driver's license must be presented at the time of employment. Incumbents must be at least 21 years of age, have maintained a valid US driver's license for at least six months, and must be able to pass a driver's screening background check.
Ability to stand, walk, bend, kneel, stoop, crouch, crawl, climb as this is a very physically active position.
Must be able to lift at least 25 pounds using proper lifting techniques or the use of a two-person lift.
Ability to operate a computer and other office equipment such as a calculator, copier, and printer.
Ability to sit, reach, climb stairs, and maneuver through narrow spaces or hallways.
Ability to assist PS with tasks of daily living.
Ability to remain in a stationary position 50% of the time as needed.
Ability to bend, reach, file, sit, stand, and move around the facility.
Ability to speak, hear, and communicate with PS, staff, and external representatives.
Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
CPR required within two weeks of hire
Registered Nurse licensed in the state of service.

Nice To Haves

American Case Management or other related certifications preferred.
Experience working with people with psychiatric disability, co-occurring disorders preferred.
Preference given to bilingual/bi-cultural applicants and applicants with lived experience of psychiatric conditions
MSN preferred

Responsibilities

Provides outreach to and engage clients enrolled in One Care.
Conducts comprehensive health assessment of enrolled clients including the medical, psychiatric, and social issues of clients served.
Organizes and facilitates the effective functioning of the Interdisciplinary Care Team (ICT), including coordinating meetings, facilitating communication, and documentation.
Monitors the client’s health status and needs and provides nursing and medical care coordination, including revising health related treatment goals and plans in collaboration with the client and the team.
Coordinates the development, implementation, monitoring, and review of the Individual Care Plan (ICP), including health care strategies.
Submits all ICP revisions in accordance with the data sharing agreement between Vinfen and One Care Plan.
Collaborates closely with PCP and other providers including, but not limited to, community resources, and assures appropriate referrals based on level of care needed to optimize outcomes and minimize risk.
Collaborates with One Care Plan, PCP, and other health care providers regarding changes in services, care transitions, crisis intervention, while focusing on continuity and quality of client care and potential efficiencies and cost-savings.
Integrates the expertise of a Long-Term Services (LTS) Coordinator, and arranges for LTS Coordinator participation in the assessment, care planning, and ongoing ICT activities, if and when applicable.
Provides self-management education and training to clients, while honoring client choices, maintaining holistic focus, and educating and supporting clients’ families and friends (following HIPAA authorization by client) regarding clients’ needs and preferences as they relate to health care.
Conducts medication reviews and reconciliation, including adjustment by protocol.
Supervises Health Outreach Worker.
Communicates and collaborates with ACCS teams and serves as a team resource.
Obtains required Prior Authorization from One Care Plan for all relevant and medically necessary services.
Responsible for follow up of a client’s admission to a planned or unplanned medical or psychiatric inpatient stay (including hospital, Rehab facility, shelter, substance abuse programs), and collaborates with client, Vinfen staff, ICT, and hospital staff to coordinate safe inpatient discharges.
Maintains frequent client contact, as indicated.
Performs other related duties, as required.