Chronic Care RN; Care Manager

CLASSIFICATION/STATUS: Non-exempt, Licensed, Full Time, Permanent

IMMEDIATE SUPERVISOR: Lead Chronic Care Nurse

SUPERVISORY RESPONSIBILITIES: None

LOCATION: Hybrid (80% on-site, 20% remote)

SALARY: Band E ($34.50 - $45.00/hour)

YOUR ROLE & IMPACT

The mission of Charles River Community Health (CRCH) is to partner with individuals and families so they can thrive and lead healthier lives by delivering the comprehensive, integrated, and equitable primary healthcare that matters most to them. As an integral member of the chronic care management (CCM) team, the Chronic Care RN (Care Manager) 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 make 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 telephone or in‑person in a variety of settings, including the health center, community, home, or an inpatient facility.

• Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with primary care providers.
• Meet the patient where he/she is; observe the patient without intervention or judgment.
• Has knowledge of common chronic medical conditions presented in the population served and is able to:
• Educate the patient on their medication conditions and medications, and build their self‑management skills;
• Use motivational interviewing to promote behavioral change.
• Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.
• Conduct medication reconciliation in conjunction with the clinical pharmacist.
• Engage members and caregivers in active care planning with a focus on medical, behavioral, social, member‑centered care needs. Coach and guide member/representative to meet bio/psycho/social goals.
• Provide 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.
• Delegate assignments to Community Health Workers and/or Patient Navigators or Social Workers, follow up on completion, and be consistently available for timely consult regarding patient matters during business hours.
• Meet regularly with medical directors and nurse care managers, and speak as needed with Primary Care, ED, and inpatient to triage program issues appropriately when patients are discharged from hospitals.
• Participate in local site operations, including team meetings.
• Actively participate in planning and growth of the program as needed, to respond to evolving needs of Mass Health ACO. 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 ACO tools and processes.
• Understand the relationship between work done in the ACO's system and the work done in EHR. Ensure that workflows are optimized to recognize and support both the ACO's system and EHR.
• Facilitate interdisciplinary consultation on patient’s behalf through participation in rounds, team meetings, and clinical reviews.
• Establish and comply with quality metrics for performance and adhere to documentation and workflow standards.
• Maintain HIPAA standards and confidentiality of protected health information.
• Adhere to departmental/organizational policies and procedures.
• Provide assistance in seasonal influenza/COVID vaccination efforts when applicable.
• 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.
• Serve as the point person for enrollees coming out of the Transitions in Care Program and moving into CCM. Take all needed…