Transitional Care Manager Jobs in Boston, MA (NOW HIRING)

Job Description:

HSL provides enhanced housing with services to seniors living in its four affordable housing locations and at partner housing sites, with the goal of improving quality of life and supporting independent living.  At its core, enhanced housing with services is a proactive approach wherein resident services staff regularly and actively reach out to each individual resident to engage with them around their health and wellness, identify areas of need/risk and provide intensive, individualized case management and support as needed and desired by the resident.

The Nurse Care Manager is a key member of the housing team working to support residents in living independently and safely for as long as possible by developing meaningful relationships with residents and providing support in a holistic way. 

The Nurse Care Manager collaborates with team members to engage residents in wellness assessments and health education, connect them to needed services, support in managing health concerns, coordinate care for residents returning from hospital or rehabilitation stays, document all resident care tasks, and partner with community providers to promote overall well-being.  This position is to work on-site at an affordable housing community in Chelsea. The position requires fluency in Spanish as the majority of the resident population is Spanish-speaking.

Hebrew SeniorLife employees set the highest standard in our commitment to redefine the experience of aging. With compassion, resilience, and determination, we make a difference in the lives of patients, residents, their families, and the broader senior care community every day. And they in ours as well. These life-changing connections give our work meaning and fuel our desire to advance our potential. To be all that we can be. At Hebrew SeniorLife, that’s uniquely possible. Because here we’re supported to always keep growing. And as we do, so does our collective impact.
Our Benefits Include
 

•   Excellent medical and dental benefits, available on your first day for positions over 24 hours/week

• A 403b retirement plan open to all employees, including per diems

• Generous paid time off

• On-site health and wellness programming

• Tuition reimbursement and scholarships

• An employee recognition program

Core Competencies:

• Commit to the organization’s core values of respect, dignity, and empowerment.

•   Able to form collaborative and trusting relationships with residents, families, and other staff.

• Work collaboratively with colleagues, both within and outside the HSL continuum.

• Listen attentively; speak respectfully; maintain confidentiality.

• Provide the highest quality of preparation and presentation.

• Committed to active outreach to residents, including engaging with them in their apartments, during programs, during meals, etc.   Being ‘out and about’, visible and connected.

•   Actively promote respect and inclusion for all residents and staff in a multicultural community.   

• Have a “can-do” service mentality.

• Accept responsibility for all tasks assigned.

• Work independently toward achieving program goals

Position Responsibilities:

• Partner with the wellness coordinator and the resident services team to provide comprehensive case management services to residents.

• Provide regular preventative outreach to all residents to check in on their needs and overall health, and develop trusting relationships with residents and their families. 

•   Conduct wellness assessments of residents to determine risk and needs.  Actively follow up on all identified needs, including finding resources, making referrals,s and ensuring residents are actively engaged in services.

• Evaluate resident medical concerns and support residents with decision-making regarding next steps, e.g., calling PCP, going to urgent care, going to the ED, or seeing a specialist. 

• Coordinate with primary care physicians and specialists, hospitals, mental health, and other community providers. Ensure effective communication around changes in status, transitions, and service utilization. 

•   Active follow-up on all hospitalizations, rehab stays, and emergency room visits.  Work with families, hospitals, rehabs, HSL Home Care, and/or VNA, ASAPs, and other providers to ensure safe discharges and ongoing services. 

•   Follow up regularly with at-risk residents to support adherence to health and wellness-related activities, medication, and treatment plans.  

• Conduct and/or coordinate group and individual education sessions on health and wellness, including medication management. 

• Track residents with special needs, such as dementia and mental health, and make appropriate referrals.

• Utilize collected data to identify, plan, schedule, and implement focused programs, such as falls prevention.

• Support and educate housing staff members about common medical conditions and how to identify and communicate status changes.

• Participate in resident services team meetings, provider meetings, and individual family meetings.

• Assist residents and family members with transition to other levels of care when needed.

• Assist with specific resident needs, such as taking vital signs, educating and assisting with Health Care Proxy and File of Life forms, arranging clinics for vaccines, and arranging other health-focused clinics, supporting residents in preparing for planned surgeries/medical tests.   

•   Document all work electronically in online software.  

• Track residents with special needs, such as dementia and mental health, and make appropriate referrals.

Qualifications:

• RN and 1 year of experience or LPN and 3 years of experience required. 

• 3 years of experience in aging services preferred, home health experience, and dementia care a plus.

• Excellent triage and critical thinking skills are required, as well as the ability to handle difficult situations. 

• Must have compassion for and a desire to work with a senior population.

• Excellent organizational and interpersonal skills, including the ability to manage multiple projects simultaneously, work efficiently, and proactively as part of a team.

• Excellent oral and written communication skills, including the ability to communicate with residents, families, and staff in a manner that conveys respect, caring, and sensitivity.

• Motivated to learn and flexible/willing to change.

• Professional, proactive, collaborative, conscientious, and results-oriented individual. 

• Optimistic and positive demeanor, good intuition, and sound judgment.

• Must be able to collect needed information and document clearly in electronic formats.

• Skills and comfort using Windows, Word and Excel required.

• Some travel in the Boston metro area for site visits and meetings is required.

• Fluency in Spanish required

Remote Type

Salary Range: