Care Manager

Job Profile Summary

This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, it focuses on performing the following Care Manager related duties: works as part of a multidisciplinary team to coordinate patients’ care in an effort to improve patient outcomes and create efficiencies. A professional individual contributor role 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/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. It is an integral member of the care team who conducts comprehensive clinical assessments, develops patient‑centered care plans, and engages the patient through motivational interviewing. The goal is to improve 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.

• 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.

• 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.

• 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 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 establishing 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…