SCO RN Care Manager

Company Overview

Thank you for your interest in a career at Neighbor Health, formerly East Boston Neighborhood Health Center! As one of the largest community health centers in the country, Neighbor Health is proud to serve the greater Boston area with a strong commitment to the health and well‑being of our patients and communities. Whether you're a nurse or physician providing direct care, a manager leading dedicated teams, or part of the essential support staff who keep our operations running smoothly — every role at Neighbor Health is vital.

Together, we’re advancing medicine and delivering the best care experience for our patients and community!

The Senior Care Options (SCO) nurse case manager acts as a liaison between patients, their families, and health care personnel to ensure efficient, prompt health care and to minimize fragmentation and duplication of services. Nurses work closely with SCO patients and their families to create a care plan with the goal of maintaining independence and safety in the community. Care plans for SCO patients address the medical and psychosocial needs of each patient and are developed in collaboration with other SCO team members to ensure implementation of the most cost‑effective plan.

Systematically assess the health status of individuals and groups and record the related health data: navigate the electronic medical record; collect data on health/symptoms from a patient; analyze and interpret recorded data, and make informed clinical judgments and decisions regarding the specific elements of nursing care mandated by a particular situation: correlate new data and symptoms with the existing medical records;

determine the appropriate response level within established guidelines. Plan and implement nursing interventions, prescribed medical or other therapeutic regimens mandated by the particular situation, scientific principles, recent advancements and current knowledge in the field; collaborate with the patient’s provider regarding the assessment and plan as indicated; dispense medications per orders/protocols; report adverse reactions to medication and/or treatments in accordance with policy.

Performs treatment and interventions as indicated or directed. Provide and coordinate health teaching required by individuals, families and groups to maintain the optimal possible level of health: educate the patient on test results, new care plans and/or other relevant health care information including the use of newly prescribed medications and/or changes in the current medication regime.

Evaluate outcomes of nursing interventions, and initiate change as indicated; assess and reassess patients as needed. Collaborate, communicate and cooperate as appropriate with other health care team members to ensure quality and continuity of care. Serve as a patient advocate, within the limits of the law. Assess a patient through obtaining patient history and performing appropriate test and observation. Demonstrate sound clinical judgement/decision making when triaging sick patients.

Provide thorough and concise documentation of patient’s histories, assessments, plans and treatments. Enter messages as staff messages or telephone encounters in the computer. Document nurse visits in Epic. Follow protocols for management of patients with chronic/acute conditions and transitions of care.

Recognize the safety needs of the elderly and ensure they receive assistance as needed. Responsible and accountable for the orientation, training and mentoring of new employees. Provide input into the development of the orientation plan for new employees. Follow established departmental policies and procedures for environmental safety and infection control. Actively participate in EBNHC programs and committees. Understand organizational structure of the department and unit routine and adhere to EBNHC policies.

Responsible for continued professional growth and development and participate in required departmental activities and meetings. Perform other duties as assigned. Interact with patients in a professional and respectful manner, reflecting their needs and concerns. Use communication…