Care Manager

Charles River Community Health; Brighton; On-site

Job description

CLASSIFICATION/STATUS: Exempt, Full Time (40 hours/week)

IMMEDIATE SUPERVISORY: Chronic Care Nurse Manager

SUPERVISORY RESPONSIBILITIES: None

PAY RANGE: Band C ($24.50 - $31.50)

WHO YOU ARE

YOUR ROLE & IMPACT

The mission of Charles River Community Health (CRCH) is to partner with individuals and families so they can thrive and lead healthier lives by delivering comprehensive, integrated, and equitable primary healthcare that matters most to them. The Care Manager works with the Chronic Care Management (CCM) team, primary care providers, pharmacists, behavioral health clinicians, community health workers, and nursing staff to identify and engage patients in care management, focusing on patient experience, improving health, and reducing cost. The Care Manager will proactively seek opportunities to care for patients, including during primary care visits, emergency department or in-patient visits, out in the community, or on the phone. This position requires flexibility and may vary from day-to-day to meet members where they are.

YOUR RESPONSIBILITIES

• Identify and assist recruitment of appropriate patients for care management from lists and referrals, in collaboration with Chronic Care RNs (CCRN), primary care providers, and the rest of the CCM team.
• Collaborate with a multidisciplinary team to assess strengths and barriers and support the achievement of goals outlined in individualized, patient-centered care plans.
• Meet the patient where they are; observe the patient without intervention or judgment.
• Coordinate appointments for patients.
• Educate patients on referral processes within CRCH and at outside hospitals.
• Connect with appropriate community and state resources as needed.
• Maintain effective relationships with patients’ families, friends, and social supports to facilitate patient care.
• Communicate effectively with CCRNs and Chronic Care Nurse Manager and escalate any concerns of patient safety as necessary.
• Maintain accurate, timely documentation of case management activities in EHR and internal documentation.
• Assist with information gathering on medication compliance with the team.
• Engage members and caregivers in active care planning with a focus on medical, behavioral, social, member-centered care needs.
• Provide care coordination, which may include facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up.
• Conduct regular follow-ups with patients to evaluate progress, promote continuity of care, and ensure improved health outcomes.
• Delegate assignments to Community Health Workers and/or Patient Navigators or Social Workers, follow up on completion, and be consistently available for timely consult regarding patient matters during business hours.
• Participate in local site operations, including team meetings and integrated care team meetings and rounds as required.
• Understand the relationship between work done in the ACO's system and the work done in EHR.
• Ensure that workflows are optimized to recognize and support both the ACO's system and EHR.
• Establish and comply with quality metrics for performance and adhere to documentation and workflow standards.
• Train other members of the CCM team and wider multidisciplinary care team, and provide coverage for team members as needed.
• Maintain HIPAA standards and confidentiality of protected health information.
• Adhere to departmental/organizational policies and procedures.
• Ensure that all care management is offered in a culturally and linguistically appropriate manner and with disability competence.
• Ensure that all necessary accommodations are consistently made for patients with disabilities.
• Promote a sense of teamwork through demonstration of self-direction and self-motivation.
• Perform other duties as assigned by the Chronic Care Nurse Manager or designee.

YOUR QUALIFICATIONS, COMPETENCIES, TRAITS

• Bachelor's degree in social sciences, social work, or other health-related field.
• BLS or CPR Certificate required.
• 1-2 years of experience working in a healthcare setting, preferably in outpatient medical settings.
• Case management, care management, or other patient care coordination experience preferred.
• Knowledge of common chronic medical conditions presented in the CRCH patient population.
• Ability to engage effectively and respectfully with a diverse patient population.
• Ability to work independently and have sound decision-making skills.
• Ability to collaborate efficiently with a multidisciplinary team.
• Prior experience with Epic preferred.
• Familiarity with MassHealth insurances and ACO preferred.
• Excellent interpersonal, communication, and organizational skills.
• Knowledge of ambulatory and clinical practices, workflows, and operations.
• Experience working with historically underserved populations preferred.
• Bilingual (English/Spanish or English/Portuguese) preferred.
• Willingness to work flexible hours to meet the organization's needs.
• Ability to travel to either Charles River Community Health site (Brighton and Waltham) as needed.
• Experience in diverse cultures with a strong commitment to promoting Diversity, Equity, and Inclusion.
• Passion for serving underserved populations in diverse settings.

WHO WE ARE & WHAT WE DO

Charles River Community Health’s mission is to partner with individuals and families so they can thrive and lead healthier lives by delivering comprehensive, integrated, and equitable primary healthcare that matters most to them.

CRCH is a comprehensive practice providing medical, pharmacy, dental, behavioral health, optical, and vision services to diverse underserved local communities. We serve over 13,500 patients annually, with 90% being low income and over 70% needing services in a language other than English.

We value caring for everyone with dignity, respect, and compassion, reducing cultural, financial, and other barriers to care, and eliminating health care disparities. We also advocate for the needs of our patients, the community, and public health causes.

OUR PROMISE

If you are passionate about providing service excellence in a mission-driven, team-oriented, and progressive organization, you will find your career as the Care Manager rewarding and impactful!

OUR BENEFITS & PERKS

Medical & Dental Insurance
Short & Long-term Disability Insurance
Generous Paid Time Off
Flexible Spending Account
Employee Assistance Program
Tickets at Work
Health Reimbursement Arrangement
Travel Reimbursement
Professional Development Opportunities
Solid track record of developing and promoting employees internally!

Charles River Community Health is strongly committed to diversity and a workplace environment that respects, appreciates, and values employee differences. CRCH is an equal opportunity employer committed to maintaining a work and learning environment free from discrimination.