Complex Care Nurse Manager

Complex Care Nurse Care Manager 

Charles River and NEW Health are members of Community Care Cooperative (C3), an organization formed by 19 Federally Qualified FQHCs located throughout the Commonwealth of Massachusetts. C3, a 501(c)(3) non- profit Accountable Care Organization (ACO), is taking responsibility for managing the cost and quality of health care for MassHealth enrollees. C3's vision is transforming the health of underserved communities. As a member of C3, Charles River and NEW Health CHC are uniquely positioned to be true innovators in transforming care for a large Medicaid population.

C3 is seeking an RN care manager to join our Complex Care Management Team. You will join our team of nurses, social workers, community health workers, providers, and pharmacists, where you will have the opportunity to make a profound impact on the lives of underserved individuals and families living with complex and/or chronic conditions.  You will connect with enrollees in person, on the phone, and in the FQHC - essentially however and wherever the enrollee needs your assistance to improve their health, better understand their illness and coordinate their care. RN care managers must be prepared to work from a FQHC, home office, or within enrollee's homes when required.

Your Responsibilities

Connect with the enrollees in person (at their primary care location, their home or another community based setting or care setting), The RN CM will be providing face-to-face interaction with enrollees and their care team when appropriate to improve enrollee care. Although face-to-face care is preferred, phone contact will be used when needed and appropriate.
Along with other members of the Complex Care Management (CCM) Team, conduct comprehensive assessments that include the medical, behavioral, and social needs of the enrollee in order to identify gaps in care and barriers to attaining improved health. Complete these assessments within specific timeframes.
Based on this assessment, and in conjunction with the enrollee, the enrollee's primary care provider, behavioral health provider, and other members of the CCM team, create and implement a care plan that will address the identified needs, remove the barriers and improve the health of the enrollee. Complete these care plans within specific timeframes.
Coordinate care by serving as the contact point, advocate and resource for the enrollee, their family and their providers, building effective relationships through trust, respect and communication.
In close collaboration with the enrollee, primary care provider, behavioral health provider, family or caregivers, continually assess the enrollee's knowledge of their clinical condition(s) and provide education and self-management support based on the enrollee's unique learning style.
Measure, improve and maintain quality outcomes (clinical, financial, and functional) for individual enrollees and the population served.
Coordinate care with Behavioral Health Community Partners (BH CPs, LTSS) and refer enrollees, as appropriate, to these and other community resources
Be fully accountable for the completion of work within established timeframes and for achieving the goals established for the enrollee/family.
Serve as the lead of the C3 CCM team at each health center; delegate duties and responsibility to other team members (ie) CHWs. Ensure that communication is optimized between the members of the CCM Team. Ensure that systems are in place to optimize communication with Community Partners for behavioral health and long term supports and services.
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.
Supports enrollees as they graduate from the CCM Team and transition into the care coordination program. Take all needed steps to ensure that this process is seamless for care team members and the enrollee/family or 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.
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 ACOs tools and processes.
Supervise staff as assigned.
Understand the relationship between work done in the ACO's system and the work done in the FQHC's EHR. Ensure that workflows are optimized to recognize and support both the ACO's system and the FQHC's EHR.
Use information about data trends for self-directed learning and performance improvement.
 

The Experience You Need (Required):

Bachelor's Degree in Nursing
2-10 years of nursing experience, preferably with some combination of home health, ambulatory care, community public health and case management work experience. Including the, coordination of enrollee care across multiple settings and with multiple providers.
Current Massachusetts Registered Nurse license
 

Finishing Touches (Preferred):

Care Management experience
Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion
Fluency in a non-English language/s
CCMC (Commission for Case Manager Certification)
Strong work ethic built on a foundation of proactivity and teamwork
Ability to navigate ambiguity with the aid of structured problem-solving techniques
Committed to the practice of inquiry and listening
Flexible work schedule may need to work evenings/ occasional weekends to provide enrollee access and/ or follow up
Computer proficiency in Microsoft Office
We are looking for team members who possess high energy, a strong work ethic, integrity, who are kind and empathetic, have a sense of humor, and who enjoy working for a collaborative, team oriented system

To Apply:  Please use link below-

https://communitycarecooperative.applicantpro.com/