Clinical Care Manager

Family Health Center • Worcester, MA

1d • Onsite

About The Position

The Clinical Care Manager is a Registered Nurse who is part of the primary care practice team and is responsible for organizing, coordinating, and providing care coordination and care management services to patients within the practice who are most at risk for health deterioration, sentinel events, and/or poor outcomes. The highest risk patients are 1) transitioning to or from home and community-based health care facilities for acute care services (hospital or emergency department), rehabilitation services, skilled nursing services, or other community based services; 2) being seen in the office with co-morbidities, unmanaged disease severity, poor selfcare, polypharmacy, and high utilization rate. The Care Manager, as an integral part of the primary care team, is responsible for ensuring that the primary care provider (PCP) and practice team maintains a central role in coordinating and managing the care of these vulnerable patients and that the patients receive optimal care including acute illness management, chronic disease management, and preventive care across multiple health settings and multiple physicians/providers.

Requirements

• BSN in nursing required.
• Minimum two years’ experience in case management, disease management, home health care nursing, or intensive outpatient education/self-management support.
• Registered Nurse (RN) license.

Nice To Haves

• Master’s Degree in Nursing preferred.
• CMCN (Certified Managed Care Nurse) or RN-BC (Registered Nurse Case Manager) preferred.

Responsibilities

• Organizing, coordinating, and providing care coordination and care management services to patients within the practice who are most at risk for health deterioration, sentinel events, and/or poor outcomes.
• Managing patients transitioning to or from home and community-based health care facilities for acute care services (hospital or emergency department), rehabilitation services, skilled nursing services, or other community based services.
• Managing patients seen in the office with co-morbidities, unmanaged disease severity, poor selfcare, polypharmacy, and high utilization rate.
• Ensuring that the primary care provider (PCP) and practice team maintains a central role in coordinating and managing the care of these vulnerable patients.
• Ensuring that patients receive optimal care including acute illness management, chronic disease management, and preventive care across multiple health settings and multiple physicians/providers.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level