RN Case Manager - Primary Care - Boston

Job Profile Summary This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses on performing the following Care Manager related duties: works as part of a multidisciplinary team to coordinate their patient's care in an effort to improve patient outcomes and create efficiencies. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. A senior level role that requires advanced knowledge of the job area typically obtained through advanced education and work experience. Typically responsible for managing projects and processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, and resolving difficult and sometimes complex problems. Job Overview This position utilizes the case management process and works closely with other members of the care team to help ensure that patients receive comprehensive and coordinated care through the continuum of care. This position is an integral member of the care team who conducts comprehensive clinical assessments, develops a patient‑centered care plan, and engages the patient through motivational interviewing. The goal is to improve the quality of care and health outcomes for selected at‑risk populations and promote the efficient delivery of health care services. The candidate assesses, plans, implements, coordinates, and evaluates the plan of care in partnership with the patient/caregiver and other members of the health care team. Job Description Minimum Qualifications Massachusetts RN licensure. Obtain appropriate state board licensure where services will be provided as a registered professional nurse or current multi‑state licensure through the enhanced Nurse Licensure Compact (eNLC) within three (3) months of hire. Three (3) years of clinical experience in an acute care setting. Basic Life Support certification or obtain within three (3) months. Preferred Qualifications Bachelor's degree. Five (5) years of experience in acute, subacute, or home care, palliative care and hospice experience is a plus. Case management certification and experience. Bilingual. Valid driver's license in current state of residence. Duties and Responsibilities The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all‑inclusive list. Other duties and responsibilities may be assigned. Prepare for patient interaction by gathering information from the patient's medical record, when available, and communicating with the healthcare provider and other clinical team members. Coordinate all aspects of care for patients across the continuum of care. Advocate for patient needs and negotiate for services as required to provide cost effective and quality care. Develop trusting, professional, caring relationships with patients and families, engaging respectfully and with an emphasis on service. Act as lead member of multidisciplinary patient care teams, including collaboration with the healthcare provider and patient/caregivers as appropriate. Perform patient assessments to identify and prioritize the patient's medical needs, behavioral health conditions, health system resources and social determinants, while also identifying patient's knowledge gaps. Make home or site visits as required. Establish goals that are patient specific and identified as part of the patient's self‑management goals. Communicate with health care providers on behalf of patients/caregivers as needed and as requested by the patient, including communicating abnormal findings and patient concerns in a timely and thorough manner. Conduct medication reconciliation and provide education and consult with the pharmacist as needed. Develop patient‑centered care plans with the patient/caregiver, providing all information to the healthcare provider, and establish appropriate timelines for achieving identified goals. Update the patient care plan as changes in status occur and communicate with the healthcare provider and other members of the treatment team as indicated. Participate in quality improvement activities to enhance clinical and operational initiatives and programs. Physical Requirements Professional office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc. Primarily a sedentary role, which involves sitting most of the time but may involve walking, standing, reaching, ascending/descending stairs and operating office equipment. Frequently required to speak, hear, communicate and exchange information. Able to see and read computer displays, read fine print, and/or normal type size print and distinguish letters, numbers and symbols. Occasionally lift and/or move up to 25 pounds. Skills & Abilities Familiarity with the target community and feels connected to that community. Excellent interpersonal, conflict resolution, and communication skills telephonically as well as face‑to‑face. Demonstrate ability to work well with people of various ages, backgrounds, ethnicities, and life experiences. A robust understanding of management of chronic health conditions and population management. Familiarity with motivational interviewing. Ability to prioritize and resolve critical issues efficiently and effectively. Detail oriented, with strong organizational skills and multi‑tasking abilities. Very strong working knowledge and proficiency with technology and business software (Microsoft Office). Experience with electronic medical records and a willingness and ability to learn and utilize new technology and procedures that will continue to develop in their role and throughout the organization. Ability to work independently with minimal supervision and as part of a team. At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day. The base pay ranges reflect the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity to ensure compensation is fair, consistent, and aligned with our business goals. Beyond base pay, Tufts Medicine provides a comprehensive total rewards package that supports your health, financial security, and career growth — one of the many ways we invest in you so you can thrive both at work and outside of it. Pay Range : $91,879.42 - $117,150.49 #J-18808-Ljbffr Tufts Medical Center