Nurse Care Manager TMIN

About Tufts Medicine Integrated Network

Our Integrated Network brings together a diversity of experienced private practice and employed physicians as well as community and academic providers. While we are one unified network, we focus on different geographic regions, with local care teams convening to ensure healthy, happy neighborhoods throughout the greater Boston region.

Location
:
Remote with occasional onsite travel required within MA

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.

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

Minimum Qualifications
:

• Massachusetts RN Licensure.
• Obtain appropriate state board 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.

Preferred Qualifications
:

• Bachelor’s degree.
• Five (5) years of experience in acute, subacute, or home care, palliative care and hospice experience 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.

• Prepares 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.
• Coordinates all aspects of care for patients across the continuum of care. Advocates for patient needs and negotiates for services as required to provide cost effective and quality care.
• Develops trusting, professional, caring relationships with patients and families, engaging respectfully and with an emphasis on service.
• Acts as lead member of multidisciplinary patient care teams, including collaboration with the healthcare provider and patient/caregivers as appropriate.
• Performs 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.
• Makes home or site visits as required.
• Establishes goals that are patient specific and identified as part of the patient’s self-management goals.
• Communicates 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.
• Conducts medication reconciliation and provides education and consults with the pharmacist as needed.
• Develops patient-centered care plans with the patient/caregiver, providing all information to the healthcare provider, and establishes appropriate timelines for achieving identified goals.
• Updates the patient care plan as changes in status occur and communicates with the healthcare provider and other members of the treatment team as indicated.
• Participates in quality improvement activities to enhance clinical and operational initiatives and programs.

• Professional office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc.
• This is largely a sedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, ascending / descending…