Register Nurse Care Manager - Middlesex /Worcester County - Hybrid

Key Responsibilities

• Receives members from the engagement and central teams, clearly communicating program expectations, including duration and goals.
• Completes self-efficacy and condition-specific screeners during the assessment and intake phase, along with behavioral health screeners like PHQ-9, GAD-7, AUDIT, and DAST-10 to identify behavioral health needs. Refers members to behavioral health programs as needed.
• Conducts in-person clinical examinations when appropriate and collaborates with care team members to determine member placement in programs of varying intensity.
• Prepares for and actively participates in case conferences, leading discussions when necessary.
• Develops a care plan in collaboration with the member, addresses social needs with the support of the Community Health Partner and supports members in achieving their care plan goals through coordinated and comprehensive care efforts.
• Conducts regular clinical visits and follow-ups per clinical program and pathway guidelines, monitoring routine therapeutic interventions and addressing member needs promptly.
• Collaborates with the care team to support a panel of assigned members, providing clinical assistance in health maintenance, chronic disease management, and co-occurring psychiatric disorder support.
• Performs medication reconciliation, administration, compliance, and education as part of member care.
• Addresses quality gaps prioritized by the contracted company and ensures thorough chart documentation and coding (ICD or CPT) to validate gap closures.
• Utilizes care facilitation tools, electronic health records, and scheduling platforms to gather data, document member interactions, organize information, track tasks, and communicate with team members and community resources.

Success Metrics

• Members have an active care plan and are enrolled into appropriate clinical programs based on identified needs.
• Support members in progressing toward and completing care plan goals and program graduation.
• Closure of quality gaps for members on assigned panel.
• Accurate and timely documentation.
• Effective collaboration with interdisciplinary care team members.
• Effective coordination of care with external providers and community resources.
• Support members through inpatient and ED transitions of care.

Job Requirements

• Education: Graduate of an accredited school of nursing (R.N.).
• Experience: 3+ Years of experience.
• Problem Solving: Strong critical thinker with sound clinical judgment who makes complex decisions independently and knows when to collaborate. Identifies system barriers to care and develops creative, practical solutions. Demonstrates a growth mindset and openness to innovative approaches to improve outcomes.
• Communication: Strong written and verbal communicator across phone, text, virtual, and in-person settings. Comfortable using technology to engage members remotely. Applies Motivational Interviewing and Trauma-Informed Care principles to build trust. Effectively translates clinical information for non-clinical audiences and actively listens to understand and address needs.
• Behavioral Competencies: Member Advocate Mission Driven, Compassionate Care, Business Acumen, Team Builder, Collaboration, Team Effectiveness, Engaged Culture, Results Driver, Strategic Clarity, Proactive Approach, Accountability, Growth Agent, Innovation.

Benefits

• Health insurance
• Life insurance
• Retail benefits
• Equity program
• Paid time off, including vacation and sick leave

Pay Range

$95,000 - $105,000

Schedule

N/A

Qualifications

• Medical Clearance (for Member-Facing Roles)

Equal Opportunity Employer

We are an equal opportunity employer, indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.