BROCKTON NEIGHBORHOOD HEALTH CENTER

Clinical Care Manager - RN

Supervisor: Director of Nursing/Chief Operating Officer

POSITION SUMMARY:

The Care Management Program works as part of a diverse team in a multicultural community health center. The RN CCM provides case management services to high risk patients hoping to achieve quality care, increase care coordination and decrease hospital admissions and ED visits. The CCM works together with a team of BH clinical care manager, community health workers, supervisor, and program manager

Principle Duties & Responsibilities

Provides care management of highest risk patients with CCC ACO to reduce risk, decrease hospital and ER utilization and improve outcomes.

Comprehensively assesses patient’s physical, mental, and psychosocial needs.

Facilitates integration of the patient/family into care coordination and care management planning and communications, assuring that the patient/family are informed and supported in decision-making.

Development of care plans that prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, and minimize hospital and ER utilizations.

Utilizes motivational interviewing strategies to assist patients in adopting healthy behaviors, improving self-care and managing chronic disease.

Ongoing evaluation and documentation of patient progress/risk status and appropriate scheduling of care manager interventions.

Participates in transitioning care for patients discharged from the hospital within 24 – 48 hours to prevent readmission and related complications.

Assists with evaluation of and appropriate follow-up care for patients seen in the emergency department to prevent further disease exacerbation, complications, or additional ER or hospital utilization.

Coordination of care with other care managers (home health care, payer care managers, etc.) and with specialists to maximize care, decrease duplication of services and promote patient safety.

Collaborates with internal staff to facilitate communication and systems of care with hospitals and emergency rooms.

Incorporates case management activities into practice and collaborates with multidisciplinary health care team to provide continuity of care of patients

Attends and actively participates in scheduled staff, clinical committee, and POD team meetings.

Attends all staff trainings, which may include: webinars, telephone calls and conferences.

Participates in continuing education for personal and professional growth.

Assists in the development of clinical protocols, policies and procedures.

Documents notes and work activity in Arcadia EMR and NextGen EMR.

Other duties as assigned.

PROFESSIONAL BEHAVIOR:

• Maintains leadership skills in a professional and objective manner.
• Demonstrates characteristics of responsibility and accountability.
• Maintains confidentiality at all times.
• Maintains discretion of conversation in work areas.
• Is pleasant, courteous, and considerate of patients, co-workers, and external professional contacts.
• Demonstrates ability to prioritize demands, work with distractions, adapt to change, exercise efficient time management, and work independently.
• Maintains appropriate chain of command.
• Participates in continuing education for personal and professional growth.

COMMUNICATIONS:

• Professional verbal, written and interpersonal communication skills required.
• Must regularly communicate relevant information learned at PCMHI meetings with assigned supervisors and staff members. This can be accomplished via regular staff meetings, departmental e-mails, memos, or communication with individual staff members.
• Cooperates with efforts of the Patient Care Committee to monitor and improve the quality of patient care provided.
• Maintains patient’s right to privacy, assuring dignity in the provision of care and is discreet in all communications, written and oral, about the patient’s care.

QUALIFICATIONS:

• Bachelor’s Degree in Nursing.
• Current Massachusetts Registered Nurse license.
• (2 years) of experience in a private practice or community health center setting.
• (1-2 years) of experience as a Case Manager.
• Previous experience in ambulatory care or public health nursing.
• Excellent organizational and communication skills.
• Outstanding clinical and assessment skills.
• Bilingual strongly preferred.

WORKING CONDITIONS:

Works in a busy community health center in a downtown business district. Long hours are sometimes required.

PHYSICAL REQUIREMENTS:

Physical demands requiring lifting of small pieces of equipment, boxes, and/or patients not to exceed 50 pounds. Mostly standing and walking required. Visual acuity sufficient for frequent reading. Hearing acuity sufficient for holding conversation with or without audio devices.

BNHC is committed to providing a safe and heathy environment for patients and staff. As a condition of employment, employees, to include new hires, are required to be fully vaccinated to include the most recent COVID 19 booster and annual flu vaccines, with the exception of those who have documented medical or religious exemptions, that must be approved by BNHC according to its protocols. Additional vaccines may be required based on the recommendation of the CDC. New hires who are not yet vaccinated for flu or COVID can arrange to be vaccinated on site.

At Brockton Neighborhood Health Center, we are dedicated to providing high quality health care that is delivered by Committed, Competent, Compassionate staff who respects the dignity, privacy, and equality of each patient and colleagues. Our team believes that Teamwork, Diversity, Respect, Customer service and Collaboration are essential for everyone to be successful in their role.

Job Type: Full-time

Pay: $82,000.00 - $96,489.00 per year

Benefits:

• 403(b) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid sick time
• Paid time off
• Referral program
• Tuition reimbursement
• Vision insurance

Medical specialties:

• Primary Care

Schedule:

• Day shift

Work setting:

• Outpatient

Ability to commute/relocate:

• Brockton, MA 02301: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Nursing: 1 year (Required)
• Case management: 1 year (Required)

License/Certification:

• RN (Required)

Willingness to travel:

• 25% (Preferred)

Work Location: In person

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