Care Management RN

Job Summary

The Care Management Nurse is responsible for care coordination at times of transitions of care, management of  high-risk/high utilization patients, and maintaining continuity of care for certain diagnostic exams.

The Care Management Nurse is an integral member of the Patient Care Team which includes physicians, nurse practitioners, team nurses, behavioral health professionals and administrative staff.  The role of the Care Management Nurse is to work, at the highest level of function allowable, as part of the Patient Care Team to provide for optimal outcomes and enhance the care provided to patients.

Qualifications

The Care Management Nurse must demonstrate excellent organizational, communication, and clinical skills. Must be comfortable with the use of technology, including electronic health record management. Working as an effective member of a team as well as working independently is required. Graduation from an accredited School of Nursing and unencumbered Massachusetts RN license is required. At least 3 years nursing experience. . Bachelors of nursing degree is preferred.

Representative Job Duties

Representative Job Duties:

The role of the Care Management Nurse is defined by three primary functions: emergency department and hospitalization tracking and outreach, health maintenance cancer screening tracking and coordination; and patient complex care management.

  • Manages and tracks patients seen in the emergency department and admitted to the hospital.
  • Reviews medical records, concisely summarizing ED notes and discharge summaries through clear and succinct documentation within the EMR to better inform providers and the primary care team of the ED/Hospital course.
  • Assists with post discharge care coordination, including patient outreach, medication reconciliation, and coordination of care between patients, primary care providers, and other care team members as needed.
  • Ensures patients have appropriate post hospitalization follow up scheduled, are educated on discharge instructions, and their follow up concerns are triaged appropriately.
  • Tracks patients with abnormal breast health and cervical cancer screenings ensuring patients understand their result and receive appropriate follow up.
  • Provides patient education and explains test results and procedures, ensuring patient understanding of plan of care
  • Manages abnormal pap smear and mammogram results, including tracking patients from the time of initial abnormal test and assisting with navigation of follow up appointments to ensure compliance with treatment plan.
  • Promotes patient engagement to participate in case management program.
  • Provides case management support to primary care departments for high risk patients, including both focused short term, and long-term patient goal centered case management
  • Participates in high risk case management meetings
  • Works closely with support staff within the population health department, serving as a clinical resource for patient navigators.
  • Demonstrates strong clinical documentation skills. 
  • Displays strong interpersonal skills, working and supporting all departments of the health center. 

 

Competitive benefits package.  Generous tuition assistance after 1 year of service.

Please send resumes to:

Email | hr@sbchc.org