The RN Care Manager works as part of the Primary and Behavioral Health Care Integration Team. Provide skilled nursing care, assessment, care planning, care management and coordination of the plan of care for a specified population of patients in need of intensive care management. RN Care Manager will provide care coordination, transitional care from inpatient to other settings, and referral to community and social support services. RN Care Manager will also participate in shared treatment planning and health promotion activities.
DUTIES AND RESPONSIBILITIES:
- Works in collaboration with the consumer, the behavioral health therapist and the primary care provider to provide care management, care coordination, and/or health promotion as needed to accomplish the shared treatment plan.
- Identify consumers needing follow-up care management, care coordination, and/or health promotion services using the EHR-based population care management registry.
- Assess consumers and recommend PBHCI Health Promotion programs.
- Initiates appropriate referrals to additional services including home care and notifies appropriate support staff of referrals to ensure authorization.
- Coordinates medical/health care appointments.
- Works with the PCP, inpatient providers, discharge planners and nurse partners to ensure efficient use of inpatient resources and a timely discharge to an appropriate setting. Makes onsite visits as indicated.
- Documents the level of understanding and response to teaching.
- Participates in quality improvement activities as required.
- Demonstrates an understanding of customer service principles by successfully completing on-line Customer Service training.
- Utilizes the principles of customer service when interacting with patients/clients, team members and staff from other departments.
- Appropriately handles or seeks support when customer service breakdowns occur.
- Demonstrates a knowledge of culture by successfully completing the on-line training on Cultural Competence.
- Utilizes an appreciation of and respect for diversity when interacting with patients/clients, team members and staff from other departments.
- Responds appropriately or seeks support when confronted with cultural biases or conflicts.
- In order to respond promptly and appropriately to emergency situations, any staff member may be assigned temporary duties which differ from those in the job description, or may be assigned temporarily to a different location or schedule.
- RN with current Massachusetts License.
- Bilingual preferred.
- History of good attendance and positive work attitude.
- Minimum of 2 years clinical experience in acute care/medical surgical settings
- Significant experience in home care and/or community settings
- Discharge planning and case management experience preferred.
- The essential job duties of this position present risk of exposure to body fluids and blood borne pathogens. Annual LCHC Bloodborne pathogen training is required.
- Hepatitis B vaccine is strongly recommended and available at no charge at the Health Center.
- Declination form must be signed if this vaccine is declined.
- Some travel to conferences and trainings may be required.
- Results of inquiry to Criminal Offender Record Investigation (CORI) must be acceptable under health center standards.
- Participate in LCHC community outreach efforts, as appropriate and as assigned
- Respect and maintain patient confidentiality in all aspects of care including use of electronic information.
- Treat all patients in a welcoming and professional manner.
- Demonstrate professionalism by appropriate attire, attendance, attitude, and behavior within the clinical setting.
- Contribute to the team effort by supporting all team members and maintaining an open and positive attitude.
- Welcome new employees and students to the team by assisting with their orientation to the team and mentoring them, as requested by NCM Supervisor.
Lynn Community Health Center (LCHC) provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, LCHC complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, and transfer, leaves of absence, compensation and training. LCHC expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of LCHC’s employees to perform their job duties may result in discipline up to and including discharge.
Job Posting ID # 17-124