Care Manager

Position Summary:

The CSS, Nurse Care Manager serves as an integral member of the healthcare team to improve the clinical and operational performance of a subset of assigned patients. The role will focus on assessing, organizing, planning and coordinating the delivery of care in conjunction with the healthcare team; and providing nursing services such as follow up visits, medication administration, medication teaching and monitoring. In addition to being responsible for clients assigned to care manage, this role is responsible for ensuring the care meets standard quality measures as dictated by the regulatory and funding agencies. The CSS, Nurse Care Manager works in person with some remote options available dependent on program and patient needs.

Job Responsibilities and Performance Standards:

Care Management Activities

* 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.

* 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.

* Assesses 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. Case loads range between 100 -150, depending on the acuity of the clients and the disease state.

* 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 ascribed 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 assess 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.

Clinical Activities

* 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 condition, including pursuing CME's and advanced certification as appropriate.

Administrative Activities

* Follows established GLFHC and CSS policies and procedure as well as regulatory policies.

* Adheres to contractual program and reporting requirements.

* Attends regular CSS and nursing meetings and seeks supervision when in doubt as to programmatic, legal or other issues.

* Participates in department, health center, and other meetings as assigned.

* Is knowledgeable and respectful of the client's privacy rights, including but not limited to federal and state regulations and consistently observes HIPAA.

* Travel between sites is required.

* Maintains licensure and remains current on disease-specific standard of care.

* Develops a professional development plan with supervisor and updates annually.

Qualifications

Experience:

* 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.

Education:

* Massachusetts Registered Nurse License (unexpired).