SCO RN Care Manager

ebnhc; New York (NY); On-site; USD 85,000 - 105,000; Full time

Job summary

NeighborHealth in Boston area is seeking a Senior Care Options (SCO) nurse case manager to coordinate patient care and collaborate with the SCO team. You will help create care plans aimed at maintaining independence and safety through direct engagement with patients and families.

The role includes assessing health status, documenting in the EMR, coordinating services, and educating patients about tests and medications.

Responsibilities

• The SCO nurse case manager acts as a liaison between patients, their families, and health care personnel to ensure efficient, prompt health care and to minimize fragmentation and duplication of services.
• Assess the health status of individuals and groups and record data in the EMR.
• Collaborate with SCO team to develop and implement cost‑effective care plans focused on independence and safety.
• Provide patient and family health education to promote understanding of test results, care plans and medications.
• Document planned interventions, outcomes and changes in patient records per policy in Epic.
• Mentor and orient new employees and participate in departmental training and activities.

Skills

Epic

Tools

Epic

Job description

Thank you for your interest in a career at NeighborHealth, formerly East Boston Neighborhood Health Center!

As one of the largest community health centers in the country, NeighborHealth is proud to serve the greater Boston area with a strong commitment to the health and well-being of our patients and communities.

Whether you're a nurse or physician providing direct care, a manager leading dedicated teams, or part of the essential support staff who keep our operations running smoothly - every role at NeighborHealth is vital. Together, we're advancing medicine and delivering the best care experience for our patients and community!

Time Type:

Full time

Department:

Senior Care Options (SCO)

All Locations:

1601 Washington Street

Position Summary:

The Senior Care Options (SCO) nurse case manager acts as a liaison between patients, their families, and health care personnel to ensure efficient, prompt health care and to minimize fragmentation and duplication of services. Nurses work closely with SCO patients and their families to create a care plan with the goal of maintaining independence and safety in the community. Care plans for SCO patients address the medical and psychosocial needs of each patient and are developed in collaboration with other SCO team members to ensure implementation of the most cost-effective plan.

Systematically assess the health status of individuals and groups and record the related health data: Navigate the electronic medical record

Collect data on health/symptoms from a patient.

Analyze and interpret recorded data, and make informed clinical judgments and decisions regarding the specific elements of nursing care mandated by a particular situation: Correlate new data and symptoms with the existing medical records

Determine the appropriate response level within established guidelines.

Plan and implement nursing intervention, , prescribed medical or other therapeutic regiments mandated by the particular situation, scientific principles, recent advancements and current knowledge in the field: Collaborate with the patient's provider regarding the assessment and plan as indicated. Dispense medications per orders/protocols.

Report adverse reactions to medication and/or treatments in accordance with policy.

Performs treatment and interventions as indicated or directed.

Provide and coordinate health teaching required by individuals, families and groups to maintain the optimal possible level of health: Educate the patient on test results, new care plans and/or other relevant health care information including the use of newly prescribed medications and/or changes in the current medication regime.

Evaluate outcomes of nursing interventions, and initiate change as indicated. Assess and reassess patients as needed.

Collaborate, communicate and cooperate as appropriate with other health care team members to ensure quality and continuity of care.

Serve as a patient advocate, within the limits of the law.

Assess a patient through obtaining patient history and performing appropriate test and observation.

Demonstrates sound clinical judgement/decision making when triaging sick patients.

Provides thorough and concise documentation of patient's histories, assessments, plans and treatments. Enters messages as staff messages or telephone encounters in the computer. Documents nurse visits in Epic.

Follows protocols for management of patients with chronic/acute conditions and transitions of care.

Recognizes the safety needs of the elderly and ensures they receive assistance as needed.

Responsible and accountable for the orientation, training and mentoring of new employees. Provides input into the development of the orientation plan for new employees.

Follows established departmental policies and procedures for environmental safety and infection control. Actively participates in EBNHC programs and committees.

Understands organizational structure of the department and unit routine and adheres to EBNHC policies

Responsible for continued professional growth and development and participates in required depart5mental activities and meetings.

Performs other duties as assigned.

Interacts with patients in a professional and respectful manner, which reflects the needs and concerns of the individual. Uses communication devices appropriately.

Promotes a sense of teamwork, maintains a positive attitude. Open to new ideas and embraces change. Provides support and direction to other members of the practice team. Promotes a culture of acceptance, support and collegiality. Shares new found knowledge willingly with team.

Solves problems independently, in teams and seeks consultation as appropriate.