RN Complex Care Manager

About the role

Established in 1980, the Greater Lawrence Family Health Center (GLFHC) is a mission-driven non-profit organization providing high-quality patient care to residents throughout the Merrimack Valley. GLFHC is nationally recognized as a leader in community medicine and is the sponsoring organization for the Lawrence Family Medicine Residency program.

Responsibilities

• Conducts Comprehensive Assessments on all patients referred into the complex care management program and formulates individualized care plans based on the patient’s needs and preferences
• Implements interventions and revises care plans as needed based on ongoing patient assessment and evaluation, including following any inpatient discharge or ED visit
• Facilitates patient outreach to assess the patient’s progression toward their goals
• Uses motivational interviewing strategies to optimize patient engagement
• Conducts medication assessments and reconciliation as appropriate and refers to the care team pharmacist as needed based on assessment
• Provides care coordination, which may include but not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up
• Facilitates case conferences as needed, including engaging community partners and other community based stakeholders who are engaging with patients
• Assesses the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support including symptom response plans based on the member’s needs and preferences
• Refers/connects patients with primary care, behavioral health, flexible services, Community Partner, respite, and other community based social services as indicated and appropriate

Qualifications

• Bi-lingual Spanish speaking
• LPN/RN with active Massachusetts license
• Licensed Practical Nurse (LPN) with Care Management experience, ASN (Associate degree in Nursing) or bachelor’s degree in Nursing (preferred)
• Case Management Certification (CCM, ANCC RN-BC) preferred
• 3-5 years of nursing experience, preferably in-home health, ambulatory care, community public health, case management, coordinating care across multiple settings and with multiple providers
• Valid driver’s license

Benefits

#GLFHC offers a great working environment, comprehensive benefit package, growth opportunities and tuition reimbursement.