Chronic Care RN (Care Manager)

Charles River Community Health; Brighton; On-site; USD 66,000 - 91,000; Full time

Job summary

Join a forward-thinking community health center as a Chronic Care RN, where you will make a significant impact on the lives of individuals with chronic conditions. This role involves collaborating closely with patients, healthcare providers, and community resources to ensure comprehensive care. You will utilize your clinical expertise and interpersonal skills to educate patients, promote self-management, and facilitate care transitions. The organization is dedicated to equity and accessibility in healthcare, making this an ideal opportunity for those passionate about serving underserved populations. Be part of a dynamic team committed to improving health outcomes and breaking down barriers to care.

Benefits

Medical & Dental Insurance

Short & Long-term Disability Insurance

Generous Paid Time Off

Flexible Spending Account

Employee Assistance Program

Professional Development Opportunities

Travel Reimbursement

Health Reimbursement Arrangement

Tickets at Work

Internal Promotion Opportunities

Qualifications

• Must be a licensed Registered Nurse in Massachusetts.
• Experience in outpatient medical settings preferred.
• Knowledge of chronic medical conditions and care management.

Responsibilities

• Identify and recruit patients for care management.
• Conduct medication reconciliation with clinical pharmacists.
• Engage members in active care planning and coordination.

Skills

Interpersonal Skills

Communication Skills

Motivational Interviewing

Clinical Knowledge

Decision Making

Cultural Competence

Education

Bachelor of Science in Nursing

Tools

Electronic Health Records (EHR)

Job description

CLASSIFICATION/STATUS: Exempt, Licensed, Full Time

IMMEDIATE SUPERVISORY: Chronic Care RN Manager

SUPERVISORY RESPONSIBILITIES: None

SALARY: Band 6 ($66,600 - $90,500/year)

WHO YOU ARE:

YOUR ROLE & IMPACT

The mission of Charles River Community Health (CRCH) is to partner with individuals and families so they can thrive and lead healthier lives by delivering the comprehensive, integrated, and equitable primary healthcare that matters most to them. We are a Community Health Center providing medical, pharmacy, dental, behavioral health, optical, and vision services to diverse underserved local communities. We serve over 13,500 patients annually, and 90% of those served are low income, while over 70% need services in a language other than English.

As an integral member of the care management team at Charles River Community Health (CRCH), the Chronic Care RN (Care Manager) 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 make 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.

YOUR RESPONSIBILITIES

• Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with primary care providers.
• Meet the patient where he/she is; observe the patient without intervention or judgment.
• Has knowledge of common chronic medical conditions presented in the population served and is able to educate the patient on their medication conditions and medications, and build their self-management skills;
• Use motivational interviewing to promote behavioral change.
• Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.
• Conduct medication reconciliation in conjunction with the clinical pharmacist.
• Engage members and caregivers in active care planning with a focus on medical, behavioral, social, member-centered care needs. Coach and guide member/representative to meet bio/psycho/social goals.
• Provide care coordination, which may include but is not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up.
• Delegate assignments to Community Health Workers and/or Patient Navigators or Social Workers, follow up on completion, and be consistently available for timely consult regarding patient matters during business hours.
• Meet regularly with medical directors and nurse care managers, and speak as needed with Primary Care, ED, and inpatient to triage program issues appropriately when patients are discharged from hospitals.
• Participate in local site operations, including team meetings.
• Actively participate in planning and growth of the program as needed, to respond to evolving needs of Mass Health ACO. Maximize the use of ACO care management tools and technology to ensure that work is comprehensive, detailed, automated and streamlined to the extent possible. Make recommendations to change workflows to enhance the ease of use, practicality, and effectiveness of the ACO tools and processes.
• Understand the relationship between work done in the ACO's system and the work done in EHR. Ensure that workflows are optimized to recognize and support both the ACO's system and EHR.
• Facilitate interdisciplinary consultation on patient's behalf through participation in rounds, team meetings, and clinical reviews.
• Establish and comply with quality metrics for performance and adhere to documentation and work flow standards.
• Maintain HIPAA standards and confidentiality of protected health information.
• Adhere to departmental/organizational policies and procedures.
• Provide assistance in seasonal influenza/COVID vaccination efforts when applicable.
• Participate in the integrated care team meetings and rounds as required.
• Maintain accurate, timely documentation in electronic systems including health center EHRs.
• Provide coverage for team members who are out of office.
• Serve as the point person for enrollees coming out of the Transitions in Care Program and moving into CCM. Take all needed steps that this process is seamless for care team members and the enrollee, family, and caregivers.
• Ensure that all care management is offered in a culturally and linguistically-appropriate manner and with disability competence.
• Ensure that all needed accommodations are consistently made for members with disabilities.
• Promote a sense of "team work” through demonstration of self-direction and self-motivation. Solve problems independently or know when to seek consultation.
• Work closely with the Chronic Care Nurse Manager and assists with the running of the CCM.
• Perform other duties as assigned by the Chronic Care Nurse Manager, or designee.

YOUR QUALIFICATIONS, COMPETENCIES, TRAITS

• Bachelor of Science degree in nursing required.
• Must be licensed in Massachusetts as a Registered Nurse
• Experience in nursing with recent clinical experience in outpatient medical setting, or other related outpatient practice, preferred.
• Must have demonstrated and solid interpersonal, communication, and management skills.
• Must be able to continually update clinical knowledge and skills through formal and informal education and review of current literature.
• Must have knowledge of ambulatory and clinical practices, workflows, and operations.
• Must work well independently, have sound decision making skills, and work effectively with and through inter-professional colleagues when required to make and facilitate complex decisions.
• Must exercise a high degree of professional judgment within scope of licensure.
• Experience working with historically underserved populations preferred.
• Experience with Patient Centered Medical Home model and concepts preferred.
• Must have a willingness to work flexible hours to meet the organization's needs/demands.
• Must be able to travel to either Charles River Community Health site (Brighton and Waltham) as needed.
• Must have excellent communication skills, particularly with people from diverse cultures whose primary language is not English, with the ability to understand the community, population, and patients we serve.
• Must have experience in diverse cultures, with strong commitment to promoting Diversity, Equity, and Inclusion and reducing inequities.
• Must believe in the work we do at CRCH, with a strong passion to serve underserved populations in diverse settings.

WHO WE ARE & WHAT WE DO

Charles River Community Health’s mission is to partner with individuals and families so they can thrive and lead healthier lives by delivering the comprehensive, integrated, and equitable primary healthcare that matters most to them.

CRCH is a comprehensive practice providing medical, pharmacy, dental, behavioral health, optical, and vision services to diverse underserved local communities. We serve over 15,000 patients annually, and 80% of those served are well below the poverty line while over 60% speak in a language other than English.

We are committed to providing patients with timely access to the right care, at the right place and at the right time, collaborating with other organizations to connect patients with a comprehensive range of services and provide continuity of care, and creating new community partnerships to meet the changing needs of patients and the community.

We value caring for everyone with dignity, respect, and compassion, reducing cultural, financial and other barriers to care, and eliminating health care disparities for our patients. We also advocate for the needs of our patients, the community, and public health causes.

OUR PROMISE

If you are passionate about providing service excellence in a mission-driven, team-oriented, and progressive organization, you will find your career as the Chronic Care RN (Care Manager) rewarding and impactful! You will be part of a dynamic and fast-paced team with a shared vision to break down barriers in delivering healthcare excellence!

OUR BENEFITS & PERKS

Medical & Dental Insurance

Short & Long-term Disability Insurance

Generous Paid Time Off

Flexible Spending Account

Employee Assistance Program

Tickets at Work

Health Reimbursement Arrangement

Travel Reimbursement

Professional Development Opportunities

Solid track record of developing and promoting employees internally

Charles River Community Health is strongly committed to diversity and a workplace environment that respects, appreciates and values employee differences and similarities. By providing and supporting a work culture that fosters and builds upon diversity and its strengths, CRCH will better serve our local communities and continue to provide quality patient care and services. CRCH is an employment at-will organization and an equal opportunity employer committed to maintaining a work and learning environment free from discrimination on the basis of sex, race, color, religion, national origin, pregnancy, gender identity, sexual orientation, marital/civil union status, ancestry, place of birth, age, citizenship status, veteran status, political affiliation, genetic information or disability, as defined and required by state and federal laws. Additionally, CRCH prohibits retaliation against an applicant or employee because he or she has engaged in protected activity under the statutes prohibiting discrimination in the workplace.