Licensed Care Manager, Nursing - Float Pool

Location: Hybrid, MA Organization Summary Community Care Cooperative (C3) is a 501(c)(3) non-profit multi-service organization governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We fulfill two primary business functions for the FQHCs we work with. First, we are an FQHC-led accountable care organization (ACO); second, we are a Management Services Organization (MSO) for FQHCs. As an ACO, we negotiate value-based payor contracts on behalf of our FQHCs, hold and operate those contracts (including fulfilling many compliance, financial management, and population health management functions), and maximize the return to FQHCs of any incentive dollars earned. We are proud to be the market leader in the MassHealth ACO Program. We are the largest Medicaid ACO in Massachusetts, and we operate a variety of business offerings nationwide. As an MSO, we (along with our subsidiary companies, which are also FQHC-led non-profits) provide several financial, operational, and technological services to groups of FQHCs. These services include Epic EHR licensing and implementation; pharmacy operations consulting as well as the building and direct operation of on-site retail pharmacies; billing and credentialing; employer-sponsored insurance; and others. We are a fast-growing, dynamic organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners. Job Summary As an integral member of the care management team, the Licensed Care Manager will have the opportunity to have 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. This position is currently hybrid, but requires flexibility, and may vary from day-to-day to meet members where they are. The Float Pool Position is hybrid though primarily remote and will cover care management vacancies at C3-affiliated FQHCs and affiliated provider groups. Responsibilities Conducts Comprehensive Clinical AssessmentsAssures that medication reconciliation is complete depending on MA state licensure. The RN CM will complete the medication reconciliation and may include a pharmacist and/or primary care Team.Engages members and caregivers in active care planning with a focus on medical, behavioral, social, member-centered care needs. Coaches and guides member/representative to meet bio/psycho/social care 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-upMay be required to meet members while they are inpatient to provide education and support about the discharge process and transition the member into care managementAssesses the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support based on the member’s needs and preferences.Connects members with primary care, behavioral health, HRSN services, respite, and other community based social services as indicated and appropriate.In collaboration with Community Health Workers, creates and maintains a comprehensive inventory of local community resources through a web-based application, improving accessibility for members and providers, and linking members with the appropriate support services.Participates in the integrated care team meetings and rounds as requiredMaintain accurate, timely documentation in electronic systems including health center EHRsProvides coverage for team members who are out of officeCompletes credentialing process per health center assignment Other duties as assigned Required Skills 3-5 years of nursing experience, preferably in case/care management, home health, ambulatory care, community public health, coordinating care across multiple settings and with multiple providersDemonstrated success in working as part of a multidisciplinary team, including communicating and working with Providers, Pharmacists, Nurses, Community Health Workers, and other health care teamsAbility to flexibly utilize clinical expertise to solve complex problemsExperience working with patients with chronic medical and behavioral health needsMust be flexible and adaptable to changeDemonstrate the ability to work independentlyMust demonstrate excellent organizational and interpersonal communication skillsAbility to balance more than one health center assignment at any given timeAbility to manage multiple EHRs for clinical documentation Desired Other Skills Bi-lingual preferredAdditional qualities that would be a good fit for our team include; Enthusiasm and passion for helping patients, genuine spirit, kind, and empathetic nature, and one who embraces a ‘go with the flow’ mentalityExperience using appropriate technology, such as computers, for work-based communicationExperience and proficiency with Microsoft Office and online record keepingExperience within the ACOs member population preferred, including Medicare/MedicaidExperience with Epic preferredExperience working with Federally Qualified Health Centers is strongly preferredExperience with anti-racism activities, and/or lived experience with racism, is highly preferred Qualifications Current, active MA Registered Nurse licenseCase Management Certification (CCM, ANCC RN-BC) preferred, though not requiredA valid driver's license and provision of a working vehicle In compliance with Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **