RN Case Manager

About the Role:

The RN Case Manager (RNCM) will work with providers and team nurses on the Infectious Disease team to assure that the patients referred for nursing case management receive patient assessment, care planning, education, follow up and support in developing and achieving their health-related self-management goal and best health outcomes. The RNCM collects, maintains, reports, and follows up on related medical data. The RNCM assists in the development of day-to-day management and long-term planning for the patient’s care. The RNCM collaborates with health center providers and multidisciplinary professionals in providing physical, psychological and/or social support for assigned patients and families. The RNCM identifies and establishes relationships with community resources which can contribute to the network of care for patients. The RNCM meets the requirements of the designated funding source in achieving required program goals.

Minimum Qualifications: 

• Graduate of an accredited nursing program.
• RN with current Mass. Licensure
• Previous experience in Community Health or Nurse Case Management preferred
• Bilingual in Spanish/Khmer/Russian beneficial
• History of good attendance and positive work attitude

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:

• 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.
• 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.
• Coordinate with other departments and agencies to best meet patient needs (i.e. Enrollment, Social Services, WIC, HAWC, BH, SBHC, Dental, Eye, Pharmacy etc.)
• Assure that patients are scheduled for follow up, lab or other pertinent visits and receive periodic phone calls to support their health maintenance activities.  Provide for follow up of no shows.
• Consistently use the learning assessment, appropriate teaching guidelines, plan of care, EHR/EPM to review and document patient interventions.

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.