C3 Registered Nurse Care Management Supervisor
Company: Community Health Connections
Posted on: June 9, 2021
As an integral member of the care management team the Registered
Nurse (RN) Care Manager (CM) will have the opportunity to make a
profound impact on the lives of people living with complex and/ or
chronic conditions, many of whom also face multiple barriers in
their lives which makes it difficult for them to achieve the
self-care required to improve their health and well-being. This
position requires flexibility and may vary from day-to-day to meet
members where they are. Outreach methods may vary based on the
needs of the organization and may include telephonic or in person
in a variety of potential settings such as but not limited to, the
health center, community, home or an inpatient facility.
Essential Duties and Major responsibilities:
- Conducts Comprehensive Assessments
- Assures that medication reconciliation is complete. The RN CM
will complete the medication reconciliation and may include a
pharmacist and/or primary care team.
- Engages members and care givers in active care planning with
focus on medical, behavioral, social, member-centered care needs.
Coaches and guides member/representative to meet bio/psycho/social
- Provide care coordination, which may include but not limited to
facilitating care transitions, supporting the completion of
referrals, and/or providing or confirming appropriate
- May be required to meet members while they are inpatient to
provide education and support about the discharge process and
transition members into care management.
- Travel throughout assigned area to engage members at their
homes or other locations where the member may be located.
- 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.
- Connects members with primary care, behavioral health, flexible
services, Community Partner, 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
- Participates in the integrated care team meetings and rounds as
- Maintain accurate, timely documentation in electronic systems
including health center EHRs.
- Provides coverage for team members who are out of office
- Ability to flexibly utilize clinical expertise to solve complex
- Experience working with patients with chronic and behavioral
- Must be flexible and adaptable to change.
- Must demonstrate excellent interpersonal communication
- Additional qualities that would be a good fit for our team
include: Enthusiasm and passion for helping patients, genuine
spirit, kind, and empathetic nature, and one who embraces a 'go
with the flow' mentality
- Experience using appropriate technology, such as computers, for
- Experience and proficiency with Microsoft Office and online
- Demonstrated success in working as part of a multi-disciplinary
team including communicating and working with Providers, Social
Workers, Community Health Workers and other health care teams.
- Demonstrate the ability to work independently
- Demonstrate understanding and commitment of the health center
- Demonstrate understanding and commitment to the established CHC
Values and Standards
- Performs other job related duties as required or assigned
In compliance with Covid-19 Infection Control practices per
- Associate degree in Nursing; Bachelor's Degree in Nursing
- Current, active MA Registered Nurse license
- 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
providersExperience working with a Medicaid population is strongly
- Experience working with Federally Qualified Health Centers is
- Bilingual in Spanish/English or Portuguese/English
- A valid driver's license and provision of a working
- Experience with anti-racism activities, and/or lived experience
with racism is highly preferred
- Computer skills for accurate data entry
- AHA BLS Health Care Provider certification or equivalent
- Demonstrated interpersonal relationship skills
- Demonstrated written and verbal communication skills in
- Demonstrated ability to work in a fast paced medical office
Keywords: Community Health Connections, Leominster , C3 Registered Nurse Care Management Supervisor, Other , Leominster, Massachusetts
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