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

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.

Apply Now

Please submit cover letter and resume to hr@sbchc.org.

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What You're Saying

“I feel that it is a well-oiled machine, with Dr. Brout at South Boston. I just can't say enough good things! They know why I am there without a computer, since everybody knows what is going on with me, all staff. Everybody is on the same page, for a level of healthcare I had never experienced.”
Family Medicine/Dr Brout
Family Medicine Patient 2022
“I like the doctors my son has. They listen, are very understanding, and seem like they care. I just like how they are with my son.”
BH Parent
Parent of Behavioral Health Patient 2022
“I like the attentiveness and feeling heard. I appreciate the fact that providers always make me feel involved in decisions.”
Behavioral Health
Behavioral Health Patient 2022
“I like that the service is more personalized because you know the people, and that is very important.”
Dental
Dental Patient 2022
“I liked that they were attentive and fast. They gave me the support I needed and were empathetic and organized. I went to a lot of departments, and all of the staff was this way.”
Family Medicine
Family Medicine Patient 2022
“The staff in the lab, Verinta or "V," is amazing. My son was literally giddy with delight at her joking and playfulness. He was actually so happy with her, he didn't react to the blood draw, but then cried outside a tiny bit with a delayed reaction like "hey, wait, that hurt." She is an absolutely phenomenal addition to the phlebotomy team! Overall, a great experience.”
May 2019
Parent of a Pediatric Patient
“Dr. Kane always asks me if I understand everything and whether or not I need further clarification... I really appreciate him explaining everything so in depth.”
2018
Eye Care Patient 2018
“There’s an emphasis on education here. Dr. Chiakpo and Marianna (a nurse in training) provided a lot of background concerning my issue and even brought in diagrams, which I greatly appreciated, since I’m a visual learner. They both gave me space to ask questions on everything. I really appreciated the time they spent with me.”
2018
Family Medicine Patient 2018
“I truly enjoyed the sweetness of Dr. Biffi. She was very detailed in her explanations, and thoroughly checked and re-checked everything. She really impressed me.The assistant was also very good, dedicated, and professional.”
2018
Eye Care Patient 2018
“My ride was late, but Dr. Green waited an hour for me. When I got there, she took me right in, so that was very nice. She gave me a prescription; she actually brought the prescription all the way outside to give it to me, since I had forgotten it. She is excellent! Everyone is very nice and very understanding. I really liked the center; everyone was very cordial to me.””
2018
Adult Medicine Patient 2018