Licensed Care Manager, Nursing (Part-Time, Fitchburg, MA)

Responsibilities

• Conducts Comprehensive Clinical Assessments
• Affirms that medication reconciliation is complete depending on MA state licensure.
• 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.
• Provides 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.
• May be required to meet members while they are inpatient to provide education and support about the discharge process and transition the member into care management.
• Assesses 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 required.
• Maintains accurate, timely documentation in electronic systems including health center EHRs.
• Provides coverage for team members who are out of office.
• Completes credentialing process per health center assignment.

Requirements

• 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 providers.
• Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Pharmacists, Nurses, Community Health Workers, and other health care teams.
• Experience working with patients with chronic medical and behavioral health needs.
• Must be flexible and adaptable to change.
• Demonstrate the ability to work independently.
• Demonstrate excellent organizational and interpersonal communication skills.
• The ability to balance more than one health center assignment at any given time.
• The ability to manage multiple EHRs for clinical documentation.

Qualifications

• A current, active MA Registered Nurse license.
• A Case Management Certification (CCM, ANCC RN-BC) preferred though not required.
• A valid driver's license and provision of a working vehicle.