RN Case Manager

Cambridge Health Alliance seeks an RN Case Manager to coordinate care for diverse, underserved patients across hospitals and community health centers. In this mission-driven, teaching-focused setting, you will conduct comprehensive assessments, develop and implement patient-centered care plans, facilitate transitions of care, and collaborate with an interdisciplinary team to address medical, behavioral health, and social needs. This role emphasizes health equity, quality improvement, and effective use of community resources while mentoring staff and learners in a supportive, collaborative environment.

Responsibilities

• Conduct comprehensive patient assessments and develop individualized care plans
• Coordinate care and services across inpatient, outpatient, and community settings
• Facilitate safe and timely care transitions and discharge planning
• Collaborate with interdisciplinary teams, patients, and families
• Advocate for patient needs with a focus on equity and access to care
• Monitor outcomes and adjust care plans based on patient progress
• Link patients to community and social service resources
• Document assessments, plans, and interventions in EMR accurately and timely
• Participate in quality improvement and population health initiatives
• Support teaching and mentoring of staff, students, and residents

Required Skills

• Clinical assessment and triage
• Care coordination and discharge planning
• Knowledge of community and social service resources
• Utilization management and insurance coordination
• Electronic Medical Records (EMR) documentation
• Interdisciplinary team collaboration
• Patient and family education
• Behavioral health integration and screening
• Population health and quality improvement
• Cultural competence and work with diverse populations