RN Care Manager - Complex Care

As an integral member of the Project SHINE clinical 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 HIV/AIDS and people at risk for HIV transmission, 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, the ability to work with high-level need communities 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.

1. Demonstrates basic – intermediate level of proficiency in the theory and practice of HIV-specific nursing care.
2. Completes nursing intakes by assessing patients through obtaining patient history and performing appropriate tests and observations.
3. Provide thorough clinical follow-up; addressing care gaps, vaccinations, and annual screenings are administered and performed.
4. Demonstrate the capacity to work with the PCP/ID Specialist and other HIV team members to develop individualized patient care plans, including adherence and outreach strategies to promote adherence for each patient.
5. Demonstrate capacity to assume a leadership role on the multi-disciplinary care team.
6. Promotes a sense of “teamwork” through demonstration of self-direction and self-motivation. Solves problems independently or knows when to seek consultation. Provides leadership to other support staff on the practice team. Works cooperatively and respectfully with others at all levels of the organization.
7. Interacts with patients and other staff in a professional and respectful manner, which reflects the needs and concerns of the individual. Maintains a positive attitude. Uses communication devices appropriately.
8. Demonstrate ability to care for and teach patients living with HIV on topics related to chronic disease management, adherence, STI screening, and safe sex.
9. Demonstrate knowledge of substance abuse conditions, major mental illness, and multiple diagnosed conditions, treatment options, and the capacity to set appropriate limits as indicated with patients.
10. Demonstrate knowledge and implementation of HIV nurse-on-call procedures, including functioning as the liaison to inpatient facilities, the on-call physician, and mental health administrator.
11. Demonstrate safe and effective patient triage, utilizing nursing process.
12. Safely and effectively administer medications, tests, and treatments as ordered. Manages the refills of all patient medications with appropriate authorization by the provider.
13. Provides thorough and concise documentation of patient’s histories, assessments, plans, and treatments. Enters messages as staff messages or telephone encounters in the computer. Enters and views patient letters in the computer. Enters exam encounters in the computer.
14. Demonstrate knowledge and implementation of Domestic Violence and Abuse Screening policy.
15. Follows established departmental policies and procedures for environmental safety and infection control. Actively participates in NeighborHealth programs and committees.
16. Utilize relevant, outside training opportunities to enhance clinical practice as indicated and disseminate pertinent information and materials to patients and team members consistent with health education role.
17. Participate in the process of grant writing and grant reporting activities related to the nursing function and service reports re: patient utilization and outcome measures.
18. Demonstrate the capacity to participate in all aspects of the quality improvement plan related to the nursing function.
19. Participates in required departmental activities and meetings: weekly clinical team meeting, Morning huddles, staff meeting, and others.
20. Flexibility to adapt to changes in department needs, scheduling, and job content.
21. Performs other duties as assigned.
22. Working with the Counseling and Testing team, as needed, performing intake STI assessments and risk assessments.
23. Responsible for managing all STD symptom screening and making appropriate referrals to ensure adequate patient care.
24. Works with Prevention & Screening team and Nurse Practitioner & ID specialist to coordinate treatment of all positive STD results received through counseling and testing and those patients referred from other departments of the Health Center and MA Department of Public Health, ensuring adequate follow-up care is provided. These patients will also be referred to the HIV nurse to be evaluated for PrEP (pre-exposure prophylaxis for the prevention of HIV) program.
25. Provide specialized nursing support for medical providers within the health center helping interpret sexually transmitted infection lab results. Providing support to health center primary care departments in giving the diagnosis of new HIV infection to patients and linking them to HIV care.
26. Responsible for evaluation and follow-up of all patients receiving treatment for Npep (post exposure prophylaxis of HIV).
27. Responsible for working with Prevention & Screening team in managing the case load of all patients receiving treatment for PrEP (pre-exposure prophylaxis of HIV) managing labs, refills, and patient education when appropriate.

1. High School Diploma required.
2. Completion of vocational/technical training beyond high school in an Accredited Nursing Program required.
3. Licensure in Massachusetts as an R.N. or L.P.N. required.
4. BCLS certification (per departmental policy) required.

1. Two years experience in HIV nursing preferred, preferably in a community health setting.
2. Previous experience working with substance abuse and/or HIV Care patients.

1. Spanish Bilingual/Bicultural skills preferred.
2. Excellent interpersonal skills.
3. Proficient in Microsoft Word.
4. Flexible hours, including weekends and evenings; 24 hour on-call rotation.

1. Medical, dental, and vision coverage.
2. Life and disability insurance.
3. 401(k) retirement plan.
4. Tuition reimbursement.
5. Flexible spending and transportation accounts.
6. Paid holidays, vacations, sick, and personal time.
7. Generous staff development benefit.
8. Excellent malpractice coverage.
9. Pet insurance.
10. Free parking.
11. And much more.

Starting at $39.85 up to $61.76 depending on experience.
$10,000 Sign-on Bonus (pro-rated for part time and per diem).