RN Complex Care Manager

Description Established in 1980, the Greater Lawrence Family Health Center (GLFHC) is a multi-site mission-driven non-profit organization employing over 700 staff whose primary focus is providing the highest quality patient care to residents throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program. GLFHC is currently seeking a Registered Nurse (RN) Care Manager (CM) to join our care management team. The RN, Care Manager will have the opportunity to make a profound impact on the lives of people living with complex and/ or chronic conditions, many of whom also face multiple barriers in their lives which makes it difficult for them to achieve the self-care required to improve their health and well-being. This position requires flexibility and may vary from day-to-day to meet members where they are. Outreach methods may vary based on the needs of the organization and may include telephonic or in person in a variety of potential settings such as but not limited to, the health center, community, home, or an inpatient facility. This role is a hybrid model with remote opportunities and onsite presence at local practice locations for team meetings is expected. Conducts Comprehensive Assessments on all patients referred into the complex care management program and formulates individualized care plans based on the patient’s needs and preferences Implements interventions and revises care plans as needed based on ongoing patient assessment and evaluation, including following any inpatient discharge or ED visit Facilitates patient outreach to assess the patient’s progression toward their goals Uses motivational interviewing strategies to optimize patient engagement Conducts medication assessments and reconciliation as appropriate and refers to the care team pharmacist as needed based on assessment 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 Facilitates case conferences as needed, including engaging community partners and other community based stakeholders who are engaging with patients May be required to meet patients while they are inpatient to provide education and support about the discharge process and transition members into care management. 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. Refers/connects patients with primary care, behavioral health, flexible services, Community Partner, respite, and other community based social services as indicated and appropriate. Qualifications: Bi-lingual Spanish speaking LPN/RN with active Massachusetts license Licensed Practical Nurse (LPN) with Care Management experience, ASN (Associate degree in Nursing) or bachelor’s degree in Nursing (preferred) 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 Valid driver’s license #GLFHC offers a great working environment, comprehensive benefit package, growth opportunities and tuition reimbursement.