The RN Complex Care Manager is responsible and accountable for organizing, coordinating, and providing care coordination and care management services to CHA's population of patients who are at high or risking risk for health deterioration, sentinel events, and/or poor outcomes. The RN Care Manager works in assigned primary care practices with an Complex Care Social Worker and Community Health Worker as an integrated complex care management team. This team collaborates with the healthcare team, specialty services, and community-based partners to ensure that care for at risk patients is coordinated and managed to deliver on the three goals of the Triple Aim – improved health outcomes, excellent patient experience of care and greater healthcare value. Complex Care Management aims to optimize healthcare and population health services for these patients by focusing on patient-centered assessment and engagement, goal setting, team facilitation, acute illness management, chronic disease management, linkage to community based resources and services, and intensive care coordination and preventive care across multiple health and community settings and multiple physicians/providers.
Education/Training: Graduate of an NLN-accredited School of Nursing, BSN required.
Licensure: Current RN license in the Commonwealth of Massachusetts
Certifications: American Heart Association BLS required. Case Management or equivalent certification preferred
Work Experience: Minimum of 5 years of broad clinical experience, including community health nursing or home care. Extensive knowledge of chronic disease management. Pediatric nursing experience strongly preferred. Demonstrated ability to work with patients with behavioral health and substance abuse conditions and/or significant psychiatric co-morbidities as well as patients requiring considerable support accessing community-based supports. Care Management Experience required. Demonstrated competency in managing a caseload of ethnically diverse patients across the continuum of care. Bi-lingual capacity (Spanish, Portuguese, Haitian Creole) highly desirable