Hiring for an ACO Nurse Care Manager in Methuen, MA
Hours: Monday thru Friday 40 hours/week (day shift)
Pay rate: $40-43/hr
MUST be bilingual in Spanish/English
Position Summary:
As an integral member of the care management team, the Nurse Care Manager (CM) will have the opportunity to make a profound impact on the lives of people living with complex and/ or chronic conditions, many of whom also face multiple barriers in their lives which makes it difficult for them to achieve the self-care required to improve their health and well-being. This position requires flexibility and may vary from day-to-day to meet members where they are. Outreach methods may vary based on the needs of the organization and may include telephonic or in person in a variety of potential settings such as but not limited to, the health center, community, home, or an inpatient facility.
Job Responsibilities and Performance Standards:
- Conduct Comprehensive Assessments on all patients referred into the complex care management program and formulate individualized care plans based on the patient’s needs and preferences.
- Implement interventions and revise care plans as needed based on ongoing patient assessment and evaluation, including following any inpatient discharge or ED visit.
- Facilitate patient outreach to assess the patient’s progression toward their goals.
- Use motivational interviewing strategies to optimize patient engagement.
- Engage members and caregivers in active care planning with focus on medical, behavioral, social, member-centered care needs.
- Coaches and guides member/representative to meet bio/psycho/social goals.
- Contribute to PCMH (Patient Centered Medical Home) care team meetings as needed and is an active member of the PCMH team.
- Conduct medication assessments and reconciliation as appropriate and refers to the care team pharmacist as needed based on assessment.
- Provide care coordination, which may include but not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up.
- Facilitate case conferences as needed, including engaging community partners and other community-based stakeholders who are engaging with patients.
- May be required to meet patients while they are inpatient to provide education and support about the discharge process and transition members into care management.
- Assess the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support including symptom response plans based on the member’s needs and preferences.
- Refer/connect patients with primary care, behavioral health, flexible services, community partner, respite, and other community based social services as indicated and appropriate.
- In collaboration with Community Health Workers, create and maintain a comprehensive inventory of local community resources through a web-based application, improving accessibility for members and providers, and linking members with the appropriate support services.
- Participate in the integrated care team meetings and rounds as required.
- Maintain accurate, timely documentation in electronic systems including health center EHRs.
- Provide coverage for team members who are out of office.
- Maintain patient caseload based on internal standards. ? Other duties as assigned.
Qualifications and Experience:
- Active RN license in MA
- Case Management Certification (CCM, ANCC RN-BC), preferred.
- 3-5 years of nursing experience, preferably in-home health, ambulatory care, community public health, case management, coordinating care across multiple settings and with multiple providers.
- Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Pharmacists, Social Workers, Community Health Workers, and other health care teams.
- Ability to flexibly utilize clinical expertise to solve complex problems.
- Experience working with patients with chronic and behavioral health needs.
- Must be flexible and adaptable to change.
- Demonstrate the ability to work independently.
- Must demonstrate excellent interpersonal communication skills.
- Additional qualities that would be a good fit for our team include: Enthusiasm and passion for helping patients, genuine spirit, kind, and empathetic nature, and one who embraces a ‘go with the flow’ mentality.
- Experience using appropriate technology, such as computers, for work-based communication.
- Experience and proficiency with Microsoft Office and online record keeping.
- Experience within the ACOs member population preferred including Medicare/Medicaid.
- Experience working with Federally Qualified Health Centers, strongly preferred.
- Demonstrated experience working with diverse patient populations and workforce.
- Valid driver’s license.
…Pay Statement and Pay Transparency Laws: rate of pay listed is on a per hour basis. You will be entitled to health insurance once employed for 60 days and you must work 30 hours per week, on average, per month to enroll and maintain health insurance through Complete Staffing Solutions. Once both qualifiers are met you must complete the enrollment packet and your benefits will start on the first of the subsequent month. ..It is our policy to provide equal employment opportunity to all individuals regardless of race, color, sex, sexual orientation, religion, disability, age, veteran status, ancestry, national or ethnic origin or any other legally protected class. We are committed to a diverse workforce. We value all employees’ talents and support an environment that is inclusive and respectful. We are strongly committed to this policy, and believe in the concept and spirit of the law.#ZIP