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C3 Registered Nurse Care Management Supervisor

Company: Community Health Connections
Location: Leominster
Posted on: June 9, 2021

Job Description:

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 goals.
  • Provide 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
  • 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 support services.
  • Participates in the integrated care team meetings and rounds as required
  • 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 problems
  • Experience working with patients with chronic and behavioral health needs
  • Must be flexible and adaptable to change.
  • Must demonstrate excellent interpersonal communication skills
  • 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 work-based communication
  • Experience and proficiency with Microsoft Office and online record keeping
  • 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 mission
  • 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 Mass.gov recommendations

Minimum Qualifications:

  • Associate degree in Nursing; Bachelor's Degree in Nursing preferred
  • 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 preferred
  • Experience working with Federally Qualified Health Centers is strongly preferred
  • Bilingual in Spanish/English or Portuguese/English Preferred
  • A valid driver's license and provision of a working vehicle
  • 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 English
  • Demonstrated ability to work in a fast paced medical office environment

Keywords: Community Health Connections, Leominster , C3 Registered Nurse Care Management Supervisor, Other , Leominster, Massachusetts

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