RN Case Manager - Recuperative Care Center

Qualifications

Graduate of an accredited nursing program.

RN with current Mass. Licensure.

Previous experience in Community Health or Nurse Case Management preferred.

Bilingual in Spanish/Khmer/Russian beneficial.

History of good attendance and positive work attitude.

Specific Duties And Responsibilities

• Establish contact with patients appropriate for RN Case Management due to diagnosis, treatment regime, risk status, compliance, recent ER usage or Grant specified target group criteria.
• In collaboration with the PCP, Team RNs, Clinical Pharmacist, other Providers, patient and family formulate a plan of care that supports best practice and guides the patient in achieving identified/revising Self Management goals.
• This plan may include medication management, diet counseling, exercise, referral for specialty care, education for proper use of medical equipment or supplies, update of immunizations, group or individual education and support.
• Cookordinate with other departments and agencies to best meet patient needs (i.e. Enrollment, Social Services, WIC, HAWC, BH, SBHC, Dental, Eye, Pharmacy etc.).
• Assure that patients are scheduled for follow up, lab or other pertinent visits and receive periodic phone calls to support their health maintenance activities.
• Provide for follow up of no shows.
• Consistently use the learning assessment, appropriate teaching guidelines, plan of care, EHR/EPM to review and document patient interventions.
• Develop and utilize patient case registry and data collection programs to track, record and summarize patient information for funding sources.