RN Case Manager

RN Case Manager - OBAT Services

The Nurse Case Manager will provide clinical nursing support for Office Based Addiction Program and for the Integrated Primary Care Teams. The Nurse Case Manager will provide skilled nursing care, assessment, care planning, care management and coordination of the plan of care for a specified population of patients in need of intensive care management. Nurse Case Manager will provide care coordination, transitional care from inpatient to other settings, and referral to community and social support services. Nurse Case Manager will also participate in shared treatment planning and health promotion activities.

Qualifications:

• Must be graduate of accredited nursing program
• Current Massachusetts Registered Nurse license
• Must have minimum of 2 years clinical experience in acute care/medical surgical settings
• Significant experience in home care and/or community settings, and discharge planning and case management experience desired.
• Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion
• Bilingual preferred.

Specific Duties And Responsibilities:

1. Establish contact with patients appropriate for RN Case Management due to diagnosis, treatment regime, risk status, compliance, recent ER usage or Grant specified target group criteria.
2. In collaboration with the PCP, Team RNs, Clinical Pharmacist, other Providers, patient and family formulate a plan of care that supports best practice and guides the patient in achieving identified/revising Self Management goals. This plan may include medication management, diet counseling, exercise, referral for specialty care, education for proper use of medical equipment or supplies, update of immunizations, group or individual education and support.
3. Coordinate with other departments and agencies to best meet patient needs (i.e. Enrollment, Social Services, WIC, HAWC, BH, SBHC, Dental, Eye, Pharmacy etc.)