Care Management Nurse (ACO)

The Dimock Center; Boston (MA); On-site; USD 52,000 - 70,000; Part time

Job summary

The Dimock Center is seeking a Care Management Nurse to join the Adult Medicine (ACO) team in Boston. This part-time, 0.5 FTE role focuses on intensive case management for high-risk patients, educating patients, and coordinating care across services within our community health center.

You will work collaboratively with the quality improvement team to meet program metrics and ensure patient-centered care, including documentation, follow-ups, and coordination of referrals as needed.

Qualifications

• Licensed/Associate degree in Nursing or related field.
• 2-3 years experience with diverse populations.
• Experience with evidence-based counseling techniques.
• Knowledge of database management, EHRs, and population health interventions.
• Team collaboration and effective communication in a care setting.

Responsibilities

• Screen and assess patients for chronic diseases.
• Engage patients in primary care and enrollment in CMN program.
• Telephone triage and determine escalation to home/clinic/emergency care.
• Educate patients on self-management and treatment options.
• Monitor symptoms and treatment side effects; adjust as needed.

Skills

Communication

Teamwork

Digital literacy

Initiative

Detail-oriented

Education

Nursing license or degree

Tools

Electronic Health Records

Job description

Care Management Nurse (ACO)

• Approved Salary: $44.46/hr
• Schedule: Part-time (0.5 FTE); 8:00am to 4:00pm
• Status: Non-exempt
• Reports To: Director of Quality Improvement & Value-Based Care or their Designee
• Department: Adult Medicine (ACO)

Summary/Objective

As part of the Care Management (CM) program, one of the Accountable Care Organization (ACO) programs from Community Care Cooperative (C3), the Care Management Nurse (CMN) is a key element in providing an intensive case management plan for high-risk and impactable patients. This short-term program enables the CMN to motivate, educate, and support progress toward self-defined health goals to prevent undesired health outcomes by meeting the standards of quality metrics established at the health center community level.

The Dimock Center highly values teamwork, respect, and maintaining a positive work environment. We serve the diverse community in and around the Roxbury neighborhood of Boston. The successful candidate will be committed to caring for patients in a community health center setting and invested in working in a team-based setting to provide comprehensive, high-quality care to patients.

Essential Functions

• Screen and assess patients for common chronic diseases.
• Facilitate patient engagement in primary care and enrollment in the program.
• Conduct phone triage of patient calls and understand which conditions need home, clinic, or emergency care.
• Provide patient education (e.g., self-management skills) about common chronic diseases and the available treatment options at the clinic.
• Monitor patients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications.
• Monitor clinic inventory and maintain all materials and equipment to proper standards.
• Support medication adherence as prescribed by medical providers, focusing on side effects and effectiveness of treatment.
• Coordinate and support health care and referrals to indicated services in and outside the clinic.
• Act as liaison between patients, families, and healthcare teams to ensure effective communication and understanding of treatment plans.
• Collaborate with the quality improvement team to enhance and refine clinical or non-clinical workflows to meet the assigned quality metrics for the population.
• Integrate clinical knowledge and managerial skills to attain desired goals established by the care team.
• Participate in regularly scheduled meetings for caseload consultation or any other concern related to the case.
• Create updated and accurate medical summaries to be shared with medical providers and any other clinician involved in the member's care.
• Track patient follow-ups and clinical outcomes using a registry, software, or the assigned system.
• Document in-person and telephone encounters in the system to identify gaps and to re-engage members.
• Document patient progress and treatment recommendations in the system to be shared with medical providers and any other clinician involved in the member's care.
• Facilitate treatment plan changes with the medical provider for patients not improving.
• Develop and complete relapse prevention self-management plans with patients who have attained their treatment goals and are soon to be discharged from the program.
• Perform other duties as assigned by supervisor.

Competencies

• Excellent oral and written communication skills.
• Self-taught, collaborative, motivated, autonomous, and detail-oriented mindset.
• Comfortable with the use of digital systems (computers, electronic documentation, other platforms).
• Adheres to policies, procedures, and regulations.
• Takes initiative in making suggestions for improvement of services.
• Utilizes human resources, time, and supplies efficiently.
• Shows ability to prioritize responsibilities and make sound clinical judgment to achieve desired results in the required time frame.
• Takes responsibility for delivery of services as part of a team effort in the department.
• Requires minimal supervision and can be depended upon to meet established standards and achieve desired results.

Work Environment

This position operates in a clinical setting.

Required Qualifications

• License/Associate's degree in Nursing or related field.
• Two to three (2-3) years of experience working with a diverse population.
• Experience with evidence-based counseling techniques.
• Knowledge of database management, electronic health records, and population health interventions.
• Demonstrated ability to collaborate and communicate effectively in a team setting.
• Ability to maintain effective and professional relationships with patients and other members of the care team.
• Experience with screening for common chronic diseases.
• Ability to effectively engage patients in a therapeutic relationship, when appropriate.
• Ability to work with patients and the care team by telephone as well as in person.
• Experience with assessment and treatment planning for common chronic diseases.
• Working knowledge of evidence-based treatments and brief interventions for common chronic diseases (e.g., motivational interviewing, problem-solving treatment).
• Basic knowledge of pharmacology for common chronic diseases that is within appropriate scope of practice.

Preferred Qualifications

• Master of Science in Nursing (MSN).
• Bachelor's degree in Nursing or related field.
• Systems thinking experience and/or training (e.g., Lean Six Sigma).
• Other degree or training relevant to health care, including completion of an MPH, MHS, MBA, or similar master's degree in public health.
• Bilingual in a language common to the population we serve.

Other Duties

This job description is not intended to cover a comprehensive listing of duties or responsibilities and may change at any time with or without notice.

EEO Statement

The Dimock Center values diversity and is committed to equal employment opportunity regardless of age, color, disability, ethnicity, marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other status protected by law.