Nurse Care Manager

Job Overview HSL provides enhanced housing with services to seniors living in its four affordable housing locations and partner sites. The Nurse Care Manager works on-site at an affordable housing community in Chelsea, plays a key role in supporting residents in living independently and safely, and must be fluent in Spanish. Responsibilities Partner with the wellness coordinator and resident services team to provide comprehensive case management services to residents. Provide regular preventive 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. Follow up on all identified needs, including finding resources, making referrals, 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, ED, or seeing a specialist). Coordinate with primary care physicians, specialists, hospitals, mental health, and other community providers; ensure effective communication around changes in status, transitions, and service utilization. Follow up on all hospitalizations, rehab stays, and emergency room visits; work with families, hospitals, rehabs, HSL Home Care, 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 (e.g., 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; support residents in preparing for planned surgeries/medical tests. Document all work electronically in online software. Qualifications RN with at least 1 year of experience *or* LPN with at least 3 years of experience. Three years of experience in aging services preferred; home health experience and dementia care a plus. Excellent triage and critical thinking skills, and the ability to handle difficult situations. Compassion for and a desire to work with a senior population. Excellent organizational, interpersonal, and communication skills. Motivated to learn, flexible/willing to change, professional, proactive, collaborative, conscientious, and results‑oriented. Optimistic and positive demeanor, good intuition, and sound judgment. Ability to collect needed information and document clearly in electronic formats. Proficiency with Windows, Word, and Excel. Fluency in Spanish required. Some travel within the Boston metro area for site visits and meetings is required. 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, and during meals. 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. Benefits Excellent medical and dental benefits, available on the first day for positions over 24 hours/week. 403b retirement plan open to all employees, including per diem staff. Generous paid time off. On‑site health and wellness programming. Tuition reimbursement and scholarships. Employee recognition program. Compensation Salary Range: $78,576.07 - $117,864.10 #J-18808-Ljbffr