Medicare ACO (R.N.) Care Manager Part Time

Part Time

• Conducts Comprehensive Assessments
• Assures that medication reconciliation is complete. The RN CM will complete the medication reconciliation and may include a pharmacist and/or primary care team.
• Engages members and care givers in active care planning with focus on medical, behavioral, social, member-centered care needs. Coaches and guides member/representative to meet bio/psycho/social goals.
• Provide care coordination, which may include but not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up
• May be required to meet members while they are inpatient to provide education and support about the discharge process and transition members into care management.
• Travel throughout assigned area to engage members at their homes or other locations where the member may be located. **
• Assesses the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support including symptom response plans based on the member’s needs and preferences.
• Connects members with primary care, behavioral health, flexible services, Community Partner, respite, and other community based social services as indicated and appropriate.
• In collaboration with Community Health Workers, creates and maintains a comprehensive inventory of local community resources through a web-based application, improving accessibility for members and providers, and linking members with the appropriate support services.
• Participates in the integrated care team meetings and rounds as required
• Maintain accurate, timely documentation in electronic systems including health center EHRs.
• Provides coverage for team members who are out of office
• Other duties as assigned

• Annual Enrollment is 48 per year.
• Open Caseload Ranges 10-20.

• Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Social Workers, Community Health Workers and other health care teams.
• Ability to flexibly utilize clinical expertise to solve complex problems
• Bi/multi-lingual preferred or experience with Language Translation Services
• Experience working with patients with chronic and behavioral health needs
• Must be flexible and adaptable to change.
• Demonstrate the ability to work independently
• Must demonstrate excellent interpersonal communication skills
• Additional qualities that would be a good fit for our team include: Enthusiasm and passion for helping patients, genuine spirit, kind, and empathetic nature, and one who embraces a ‘go with the flow’ mentality
• Experience using appropriate technology, such as computers, for work-based communication
• Experience and proficiency with Microsoft Office and online record keeping

• Experience working with the Medicare population is strongly preferred
• Experience working with Federally Qualified Health Centers is strongly preferred
• Associate degree in Nursing; Bachelor’s Degree in Nursing preferred
• Current, active MA Registered Nurse license
• Case Management Certification (CCM, ANCC RN-BC) preferred
• 3-5 years of nursing experience, preferably in-home health, ambulatory care, community public health, case management, coordinating care across multiple settings and with multiple providers
• A valid driver's license and provision of a working vehicle
• Experience with anti-racism activities, and/or lived experience with racism is highly preferred