RN, Care Manager

About the role

Founded in 1980, Greater Lawrence Family Health Center (GLFHC) is a mission-driven, multi-site nonprofit serving residents across the Merrimack Valley. With a staff of over 700, GLFHC is dedicated to providing high-quality, compassionate, and accessible patient care. Our Community-Based Services focus on meeting individuals where they are through evidence-based, person-centered approaches that reduce harm, improve health outcomes, and connect people to supports without judgment or unnecessary barriers. Through our programs, we provide counseling, treatment referrals, immunizations, and harm reduction services, including syringe access and Narcan education.

Responsibilities

• Conducts an intake on all new patients; in conjunction with the patient, implements a culturally competent plan of care that will help the client achieve their health goals and evaluates the plan per disease protocol.
• Provides initial and ongoing education on the relevant disease state and counseling on prevention, harm reduction and adherence support.
• Carefully coordinates patient care with other members of the medical team, including PCP, specialist, MA and CHW care manager, recovery coach/peer, nutritionist, pharmacist, and any other members of the team.
• Coordinates and/or provides outreach efforts to new patients to assist them engage in care.
• Affirms progress toward goals based on clinical judgment and review of trends in clinical data.
• Maintains an up-to-date client list with relevant quality indicators.
• Prepares documentation for case conference and participates in case discussions.
• Coordinates client care during transitions, such as intakes, discharge, institutionalizations (i.e. correctional facilities), hospitalizations, etc.
• Utilizes assigned processes for managing the needs of complex patients, initiating interventions based on physician-approved patient-specific protocols and order sets.
• At the request of the patient, participates in or facilitates partner notification and family education.
• Regularly assesses progress toward goals and identifies patients who are not adhering to their medical plan (medical visits, laboratory evaluations, pharmacy pickups) and provides outreach, including home visits, to assess barriers to care, provide education and counseling and assists client in accessing medical care and treatment.
• Documents care management and utilizations in accordance with the program requirements in external systems in addition to the EMR.
• Participates and leads the specialty clinics by preparing a pre-visit document, scheduling patients, managing clinic flow, and coordinating services for the patient.
• Provides patient care (adherence assessment, education and counseling, immunizations) in these specialty clinics.
• Conducts follow-up nursing visits for patients as relevant.
• Documents each contact with patient or outside agency in the EMR according to protocol.
• Provides direct patient care which may include immunizations, phlebotomy, and directly observed therapy via injectable and or oral medications.
• Remains current in the diagnosis, treatment and management of specialty conditions, including pursuing CME's and advanced certification as appropriate.

Qualifications

• Minimum of 2 years’ experience in nursing care.
• Valid CPR certification.
• Bilingual Spanish/English strongly preferred.
• Experience in care management or care coordination preferred.
• Knowledge of clinical and cultural issues involved in the care of Latino, African American and gay, lesbian and transgender as well as those with substance abuse.
• Strong clinical and assessment skills.
• Outstanding communication skills, self-motivation, organization and flexibility; commitment to improve care in underserved population; collaborative work style; relationship building by meeting directly with patients, families and providers in various settings; high level of accountability; reliable transportation; computer skills.
• Valid Massachusetts Driver’s license and access to reliable transportation.