RN Care Manager

Job Description Who We Are: Since 1985, BHCHP’s mission has been to ensure unconditionally equitable and dignified access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. Over 10,000 homeless individuals are cared for by Boston Health Care for the Homeless Program each year. We are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental care to cancer treatment. Our clinicians, case managers, and behavioral health professionals work in more than 30 locations to serve some of our community’s most vulnerable—and most resilient—citizens. From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity; centering dignity, compassion, mutual respect and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down barriers, including systemic racism which harms us all. We provide community-based health care services that are compassionate, dignified, and culturally appropriate, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face. Bilingual, Bicultural, LGBTQIA-identifying, Black, Indigenous, and People of Color are encouraged to apply. To learn more about working at BHCHP, watch our video Please Click Here. Job Summary: ***NOW OFFERING A $4,000 SIGN-ON BONUS*** Hours: Part‑time; 24 hours per week, Monday - Friday 8:30 am‑5:00 pm. Within Boston Health Care for the Homeless Program (BHCHP), the percentage of patients served who are age 60+ has more than doubled from 9% in 2007 to 23.2% in 2022. Among older adults served by BHCHP, over 70% have more than one chronic health condition, with some patients experiencing as many as 10 co‑occurring conditions. Many high‑risk patients are eligible to receive care‑management services, however, these services are no longer supported after the age of 65, leaving them without these essential supports at a time when their healthcare needs are increasing. BHCHP is looking for a Registered Nurse Care Manager (RN) to join a new Senior Care Team aimed at bridging the gap in services for the growing aging homeless population. This is an exciting opportunity for a nurse who would like to have a lasting impact on a team and its patients by being a part of its inception. The RN will play a crucial role in BHCHP's Senior Care Team, working alongside a gerontologist and a case manager to provide specialized care to senior patients. By participating in collaborative decision‑making for workflows and standards—including the assessment tools, documentation practices, and referral processes—the RN will help shape the future of care for homeless seniors at BHCHP. The RN is tasked with embodying BHCHP’s mission through hands‑on patient care and active participation in program development. The RN will collaborate with the Senior Care Team to oversee a panel of patients and provide supplementary backing to BHCHP's existing primary care framework. This role primarily involves outreach, encompassing in‑person patient meetings within the community, telephonic engagement with patients, liaising with providers regarding patient requirements, and facilitating patient access to diverse services such as visiting nursing, nutrition, and social services. Responsibilities: Participate in creating workflows and standards for caring for seniors who have experienced homelessness or are currently experiencing homelessness. Provide direct patient care as part of a multidisciplinary outreach team. This includes home visits, and outreach to hospitals, homeless shelters, and other settings, as needed; employ a trauma‑informed and harm‑reduction approach to caring for patients with a history of serious mental illness and/or substance use disorder. Collaboratively participate as a member of the primary care team that includes Providers, RNs, Behavioral Health Clinicians, Medical Assistants, Case Managers and others; implement prevention & engagement strategies in partnership with Senior Care Team members; work with the team to determine appropriate health assessments for this program, provide clinical oversight and tracking for comprehensive health assessments for enrolled patients. Use data to evaluate outcomes of targeted interventions for panel and assist in developing appropriate adjustments to care plans based on this data. Connect enrollees to various needed supportive services and resources such as visiting nursing, nutrition, and social services. Communicate clearly and professionally with other members of the interdisciplinary team as well as with patients and caregivers. Conform to BHCHP standards of performance around patient rights, customer service, infection control, safety procedures and culturally competent care. Remain flexible in duties as role expands and is available for assistance with other projects as needed. Qualifications: Basic Knowledge/Skills: Strong nursing assessment skills Interest in working with disadvantaged groups and elder care; understanding of substance use disorder and mental health Must be well organized, efficient and be able to work autonomously and within a team. Must be able to collaborate with multidisciplinary teams to achieve best patient care Proficient with Microsoft Suite and ability to adapt to technological changes Timely and strong communication skills via phone, e‑mail, and internal secured messaging systems; ability to prioritize and have attention to timetables to complete tasks Willingness to travel to outreach/various sites; valid driver’s license and car required or strongly recommended to travel to multiple sites Fluency in Spanish or Haitian Creole, a plus Education and Experience: Licensed as RN in Commonwealth of Massachusetts; 1‑2 years RN experience preferred Previous community health center or primary care experience; demonstrated interest in public health, primary and preventive nursing and working with an under‑served population Experience working with people experiencing homelessness, strongly preferred Mental Health experience, including knowledge of trauma‑informed care, a plus Lived experience, a plus Benefits: ***NOW OFFERING A $4,000 SIGN-ON BONUS*** The hourly compensation starts at $35.22, and increases based on years of experience. BHCHP full‑time employees are eligible for our competitive time‑off policy of 4 weeks’ vacation , health, dental and vision insurance, 403B retirement savings plan and employer retirement contribution, and pre‑tax MBTA pass program with 40% discount. In addition, eligible employees will receive yearly increases, additional compensation of seven thousand five hundred dollars added to your base hiring rate for demonstrated bilingual proficiency and the opportunity to work with local hospitals and community health centers. Does this amazing opportunity interest you? Then we'd love to hear from you. As an Equal Opportunity Employer, BHCHP pledges not to discriminate against and encourages those from underrepresented and underserved backgrounds to apply, particularly Black, Indigenous, and People of Color (BIPOC), LGBTQIA identifying, first‑generation college students and adults without a college degree, Bilingual and Bicultural persons; and individuals from low economic backgrounds. Covid‑19 Vaccination: Proof of Covid‑19 vaccination(s) is optional for employment. Candidates who are offered employment will be given details about how to demonstrate receipt of vaccination if they choose to. Please Note: Employment at Boston Health Care for the Homeless is at‑will. Boston Health Care for the Homeless does not sponsor work authorization visas. #J-18808-Ljbffr