RN Case Manager - Primary Care - Boston

Job Profile Summary

This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses on performing the following Care Manager related duties: works as part of a multidisciplinary team to coordinate their patient's care in an effort to improve patient outcomes and create efficiencies. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs.

The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. A senior level role that requires advanced knowledge of the job area typically obtained through advanced education and work experience. Typically responsible for managing projects and processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, and resolving difficult and sometimes complex problems.

This position utilizes the case management process and works closely with other members of the care team to help ensure that patients receive comprehensive and coordinated care through the continuum of care. This position is an integral member of the care team who conducts comprehensive clinical assessments, develops a patient‑centered care plan, and engages the patient through motivational interviewing. The goal is to improve the quality of care and health outcomes for selected at‑risk populations and promote the efficient delivery of health care services.

The candidate assesses, plans, implements, coordinates, and evaluates the plan of care in partnership with the patient/caregiver and other members of the health care team.

• Massachusetts RN licensure.
• Obtain appropriate state board licensure where services will be provided as a registered professional nurse or current multi‑state licensure through the enhanced Nurse Licensure Compact (eNLC) within three (3) months of hire.
• Three (3) years of clinical experience in an acute care setting.
• Basic Life Support certification or obtain within three (3) months.

• Bachelor's degree.
• Five (5) years of experience in acute, subacute, or home care, palliative care and hospice experience is a plus.
• Case management certification and experience.
• Bilingual.
• Valid driver's license in current state of residence.

The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all‑inclusive list. Other duties and responsibilities may be assigned.

• Prepare for patient interaction by gathering information from the patient's medical record, when available, and communicating with the healthcare provider and other clinical team members.
• Coordinate all aspects of care for patients across the continuum of care. Advocate for patient needs and negotiate for services as required to provide cost effective and quality care.
• Develop trusting, professional, caring relationships with patients and families, engaging respectfully and with an emphasis on service.
• Act as lead member of multidisciplinary patient care teams, including collaboration with the healthcare provider and patient/caregivers as appropriate.
• Perform patient assessments to identify and prioritize the patient's medical needs, behavioral health conditions, health system resources and social determinants, while also identifying patient's knowledge gaps.
• Make home or site visits as required.
• Establish goals that are patient specific and identified as part of the patient's self‑management goals.
• Communicate with health care providers on behalf of patients/caregivers as needed and as requested by the patient, including communicating abnormal findings and patient concerns in a timely and thorough manner.
• Conduct medication reconciliation and provide education and consult with the pharmacist as needed.
• Develop patient‑centered care plans with the patient/caregiver, providing all information to the healthcare provider, and…