Bilingual Nurse Care Manager ($40-43/hr)
14 days ago
Lincoln
Job DescriptionHiring for an ACO Nurse Care Manager in Methuen, MA Hours: Monday thru Friday 40 hours/week (day shift) Pay rate: $40-43/hr MUST be bilingual in Spanish/English Position Summary: As an integral member of the care management team, the Nurse 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. 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. Job Responsibilities and Performance Standards: • Conduct Comprehensive Assessments on all patients referred into the complex care management program and formulate individualized care plans based on the patient’s needs and preferences., • Implement interventions and revise care plans as needed based on ongoing patient assessment and evaluation, including following any inpatient discharge or ED visit., • Facilitate patient outreach to assess the patient’s progression toward their goals., • Use motivational interviewing strategies to optimize patient engagement., • Engage members and caregivers in active care planning with focus on medical, behavioral, social, member-centered care needs., • Coaches and guides member/representative to meet bio/psycho/social goals., • Contribute to PCMH (Patient Centered Medical Home) care team meetings as needed and is an active member of the PCMH team., • Conduct medication assessments and reconciliation as appropriate and refers to the care team pharmacist as needed based on assessment., • Provide care coordination, which may include but not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up., • Facilitate case conferences as needed, including engaging community partners and other community-based stakeholders who are engaging with patients., • May be required to meet patients while they are inpatient to provide education and support about the discharge process and transition members into care management., • Assess the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support including symptom response plans based on the member’s needs and preferences., • Refer/connect patients with primary care, behavioral health, flexible services, community partner, respite, and other community based social services as indicated and appropriate., • In collaboration with Community Health Workers, create and maintain 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., • 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., • Active RN license in MA, • Case Management Certification (CCM, ANCC RN-BC), preferred., • 3-5 years of nursing experience, preferably in-home health, ambulatory care, community public health, case management, coordinating care across multiple settings and with multiple providers., • Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Pharmacists, Social Workers, Community Health Workers, and other health care 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., • Additional qualities that would be a good fit for our team include: Enthusiasm and passion for helping patients, genuine spirit, kind, and empathetic nature, and one who embraces a ‘go with the flow’ mentality., • Experience using appropriate technology, such as computers, for work-based communication., • Experience and proficiency with Microsoft Office and online record keeping., • Experience within the ACOs member population preferred including Medicare/Medicaid., • Experience working with Federally Qualified Health Centers, strongly preferred., • Demonstrated experience working with diverse patient populations and workforce.