Community Care Cooperative Care Manager - Boston, Massachusetts
As an integral member of the care management team, the RN and/or Behavioral Health (BH) Care Manager (CM) 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 makes 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. The Float Pool Position is hybrid though primarily remote and will cover care management vacancies at C3-affiliated FQHCs and affiliated provider groups.
Job Responsibilities:
- Conducts Comprehensive Clinical Assessments.
- Assures that medication reconciliation is complete depending on MA state licensure. The RN CM will complete the medication reconciliation and may include a pharmacist and/or primary care team. BHCM will facilitate medication reconciliation with pharmacist and/or primary care team.
- Engages members and caregivers in active care planning with a focus on medical, behavioral, social, and member-centered care needs.
- Coaches and guides member/representatives to meet bio/psycho/social care goals.
- Provides 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.
- May be required to meet members while they are inpatient to provide education and support about the discharge process and transition the member into care management.
- Assesses the member's knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support based on the member's needs and preferences.
- Connects members with primary care, behavioral health, flexible services, Community Partners, respite, and other community-based social services as indicated and appropriate.
- In collaboration with Community Health Workers, creates and maintains a comprehensive inventory of local community resources through a web-based application, improving accessibility for members and providers, and linking members with the appropriate support services.
- Participates in the integrated care team meetings and rounds as required.
- Maintains accurate, timely documentation in electronic systems including health center EHRs.
- Provides coverage for team members who are out of office.
- Other duties as assigned.
Required Skills:
- 3-5 years of nursing experience, preferably in-home health, ambulatory care, community public health, case/care management, coordinating care across multiple settings and with multiple providers or 2-3 years of inpatient or community social work experience providing patient-centered outreach, behavioral health services, needs assessment and support.
- Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Pharmacists, Nurses, Community Health Workers, and other healthcare teams.
- Ability to flexibly utilize clinical expertise to solve complex problems.
- Experience working with patients with chronic and behavioral health needs.
- Must be flexible and adaptable to change.
- Demonstrate the ability to work independently.
- Must demonstrate excellent interpersonal communication skills.
Qualifications:
- Current, active MA Registered Nurse license or Licensed Clinical Social Worker (LCSW or LICSW), or Licensed Mental Health Counselor (LMHC).
- Associate degree in Nursing; Bachelor’s Degree in Nursing preferred or Master’s degree in Psychology, Social Work, or related field.
- Case Management Certification (CCM, ANCC RN-BC) preferred though not required.
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