RN Case Manager C3

About the Role:

Lynn Community Health Center is seeking RN Case Manager to join our Complex Care Management Team. You will join our team of nurses, social workers, community health workers, providers, and pharmacists, where you will have the opportunity to make a profound impact on the lives of underserved individuals and families living with complex and/or chronic conditions. You will connect with enrollees in person, on the phone, and in the FQHC - essentially however and wherever the enrollee needs your assistance to improve their health, better understand their illness and coordinate their care. RN care managers must be prepared to work from a FQHC, home office, or within enrollee’s homes.

Minimum Qualifications: 

• Bachelor’s Degree in Nursing
• Current Massachusetts Registered Nurse license
• Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion
• Strong work ethic built on a foundation of proactivity and teamwork 
• Ability to navigate ambiguity with the aid of structured problem-solving techniques Committed to the practice of inquiry and listening 

Preferred Qualifications:

• Certification in Case Management (CCM) or a related specialty.

• Experience working with patients in substance use treatment programs.
• Knowledge of community resources and support services for individuals with substance use disorders.

Responsibilities:

• Connect with the enrollees in person (at their primary care location, their home or another community based setting or care setting), The RN CM will be providing face-to-face interaction with enrollees and their care team when appropriate to improve enrollee care. Although face-to-face care is preferred, phone contact will be used when needed and appropriate. 
• Along with other members of the Complex Care Management (CCM) Team, conduct comprehensive assessments that include the medical, behavioral, and social needs of the enrollee in order to identify gaps in care and barriers to attaining improved health. Complete these assessments within specific timeframes.
• Based on this assessment, and in conjunction with the enrollee, the enrollee’s primary care provider, behavioral health provider, and other members of the CCM team, create and implement a care plan that will address the identified needs, remove the barriers and improve the health of the enrollee. Complete these care plans within specific timeframes. 
• Coordinate care by serving as the contact point, advocate and resource for the enrollee, their family and their providers, building effective relationships through trust, respect and communication.
• In close collaboration with the enrollee, primary care provider, behavioral health provider, family or caregivers, continually assess the enrollee’s knowledge of their clinical condition(s) and provide education and self-management support based on the enrollee’s unique learning style.
• Measure, improve and maintain quality outcomes (clinical, financial, and functional) for individual enrollees and the population served.
• Coordinate care with Behavioral Health Community Partners (BH CPs, LTSS) and refer enrollees, as appropriate, to these and other community resources

Skills:

The required skills for this position include strong assessment and critical thinking abilities, which are essential for developing effective care plans tailored to each patient's needs. Excellent communication skills are vital for collaborating with a multidisciplinary team and for educating patients and their families about treatment options. Organizational skills are necessary to manage multiple cases efficiently and ensure timely follow-up with patients. Preferred skills, such as knowledge of community resources, enhance the RN Case Manager's ability to connect patients with additional support services. Overall, these skills contribute to a comprehensive approach to patient care, fostering a supportive environment that promotes recovery and well-being.