RN Care Manager (C3) / Public Health Nurse

Upham's Community Care•Boston, MA

12d•$36 - $65•Onsite

About The Position

The Community Care Cooperative (C3), Registered Nurse (RN) Care Manager/Public Health Nurse functions under the supervision of the Director of Nursing and overall guidance and consultation with the Medical Director and other Primary Care Providers to conduct patient monitoring, tracking, and provide ongoing care coordination and support to patients enrolled as members of the Community Care Cooperative (C3), Accountable Care Organization. The C3 RN Case Manager ensures patients’ adequate linkages with chronic diseases management care and other specialty areas such as behavioral health counseling, all levels of substance use care, including medication assisted treatment. Community Care Cooperative (C3) is a 501(c)(3) not-for-profit, Accountable Care Organization (ACO) governed by FQHCs. Our mission is to leverage the collective strengths of Federally Qualified Health Centers (FQHCs) to improve the health and wellness of the people we serve.

Requirements

Licensed as Registered Nurse in Massachusetts.
Two years of nursing experience, preferably in an ambulatory care or community health setting preferred.
Experience with case management and care coordination in a community health setting.
Experience with EMR and related care management registries, databases and Information Technology/Computer Systems.
Excellent communication and clinical judgment skills.
Ability to follow and adhere to care model’s operating procedures and standards.
Cultural competency/experience with diverse settings and working on a multi-disciplinary team.
Commitment to community/public health.
Maintain awareness and experience with topics/subject areas of Harm Reduction, Aging Population, Addiction/Behavioral Health, and Social Determinants of Health and Health Disparities within communities and special populations.
Experience with case management and care coordination.
Good knowledge of common computer programs and use with an EHR or willingness to learn.
Experience or a desire to work in a multicultural community setting and with low-income populations; sensitivity to socio-economic, trauma, and other factors impacting communities with high needs.

Nice To Haves

Familiarity with UCC neighborhoods and agencies is an added plus.
Bilingual language skills in English/Spanish, Portuguese or Vietnamese desirable.

Responsibilities

Receive and maintain a log of all patients enrolled in C3 and ensure adequate follow up and care coordination.
Serve as Clinical Care Manager for enrollees referred to the RN Case Manager, participating in the assessment, care planning, and on-going C3 service provision specified in program protocols and policies.
Conduct comprehensive assessments and intakes, including but not limited to medical history, history of HIV disease, other medical conditions and client’s presenting request.
Assure that medication reconciliation is complete. This may include a pharmacist and/or primary care team.
Triage telephone questions and requests from patients.
Engage members and care givers in active care planning with focus on medical, behavioral, social, member-centered care needs; and coach, educate, and guide members/clients to meet bio/psycho/social goals.
Provide care coordination, which may include but not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up.
May be required to meet members on an in-patient basis to provide education and support about the discharge process and transition members into care management.
Assess the member’s knowledge of their medical, behavioral health and/or social conditions; and provide education and self-management support including symptom response plans based on the member’s needs and preferences.
Connect members with primary care, behavioral health, flexible services, Community Partner, respite, and other community based social services as indicated and appropriate.
Participate in the integrated care team meetings and rounds as required.
Maintain accurate, timely documentation in electronic systems including health center EHRs.
Make “warm handoffs” and coordinate support to needed services at external organizations including hospitals, substance use treatment programs, etc.
Follow up with members post-discharge to ensure members are seen by a Primary Care provider in a timely manner.
Monitor and track patients including progress in their treatment plan and update PCPs and other members of the team.
Participate in multi-disciplinary team meetings, utilization review, and program planning.
Participate in consultation, sharing of resources and best practices with other C3 care coordination staff/teams.