RN Complex Care Manager (CCM) Care Manager will report to the Manager of ACO and Care Management. The Complex Nurse Care Manager will work collaboratively with Primary Care Providers (PCP) in all Clinical areas to manage patients with Chronic Diseases, specializing in Diabetes management. The Complex Care Nurse Manager conducts comprehensive clinical assessments, develops a patient-centered care plan and engages the patient through motivational interviewing. The goal is to improve the quality of care and health outcomes for selected at-risk populations and to promote the efficient delivery of health care services. The Complex Nurse Care Manager assesses, plans, implements, coordinates, and evaluates the plan of care in partnership with the patient/caregiver and other members of the health care team. Other duties consist of participation in ongoing program development, evaluation and routine department operations.

Primary Responsibilities:

CARE MANAGEMENT

• Prepare for patient interaction by gathering information from the patient's medical record, when available, and communicating with the healthcare provider, and other clinical team members.
• Coordinates all aspects of care for patients across the continuum of care. Advocates for patient needs and negotiates for services as required to provide costs effective and quality care.
• Develops trusting, professional, caring relationships with patients/caregivers, engaging respectfully and with an emphasis on service.
• Acts as lead member of multidisciplinary patient care teams, including collaboration with the healthcare provider and patient/caregiver as appropriate.
• Performs patient assessments to identify and prioritize the patient's medical needs, behavioral health conditions, health system resources and social determinants, while also identifying patient's knowledge gaps.
• Establishes goals that are patient specific and identified as part of the patient's self-management goals.
• Communicates with health care providers on behalf of patients/caregivers as needed and as requested by the patient, including communicating abnormal findings and patient concerns in a timely and thorough manner.
• Conducts medication reconciliation and provides education and consults with the pharmacist as needed.
• Develops patient-centered care plans with the patient/caregiver, providing all information to the healthcare provider, and establishes appropriate timelines for achieving identified goals.
• Updates the patient care plan as changes in status occur and communicates with the healthcare provider and other members of the treatment team as indicated.
• Provides telephonic care management to reinforce education, evaluate progress towards goal achievement while utilizing identified teaching materials and evidence-based best practices.
• Assists and supports each patient as health-related needs are identified by the patient or health care provider.
• Facilitates patient empowerment, self-efficacy and self-management by promoting informed, shared decision making.
• Completes documentation on visits and interventions per policies.
• Facilitates communication and collaboration among payors, providers, and community agencies to meet the needs of patients/caregivers to promote continuity of care.
• Maintains collaborative, team relationships with peers, colleagues and affiliated establishments in order to effectively contribute to the organizational goals and to help foster a positive work environment.
• Performs other similar and related duties as required or directed.

KNOWLEDGE AND SKILLS

• Excellent interpersonal, conflict resolution, and communication skills telephonically as well as face-to-face.
• Demonstrates ability to work well with people of various ages, backgrounds, ethnicities, and life experiences.
• A robust understanding of management of chronic health conditions and population management.
• Demonstrates an understanding of State and Federal laws and regulations pertaining to Patient Care, Patient Rights, and privacy (HIPPA , Patient Rights, CMS) impacting
• the care delivery and reimbursement processes.
• Demonstrates a basic understanding of regulatory and reimbursement guidelines.
• Advanced communication skills required such as motivational interviewing.
• Ability to synthesize and present complex information while adapting to the audience's level of understanding and development.
• Ability to prioritize, problem solve and resolve critical issues efficiently and effectively.
• Detail oriented, with strong organizational skills and multi-tasking abilities.
• Very strong working knowledge and proficiency with technology and business software (Microsoft Office).
• Experience with Electronic Medical Records and the willingness and ability to learn and utilize new technology and procedures.
• Ability to work independently with minimal supervision and as part of a team.
• Routinely participates in continuing education opportunities to remain current in evidence based practice.
• Participates in quality improvement activities to enhance clinical and operational initiatives and programs.
• Fluency in second language preferred but not required.

Qualifications:

• Certification as a Case Manager and experience in case management strongly desired.
• Required to sit for the Certified Case Manager (CCM) exam within 2 years of date of hire. (Eligible to take exam after: 12 months of acceptable full-time case management employment, supervised by a CCM 2-4 years).
• Experience in primary care, sub-acute, home care, palliative care or hospice a plus.
• Experience working with diverse populations preferred.

CODMAN SQUARE HEALTH CENTER MISSION, VISION, AND VALUES

Mission: To serve as a resource for improving the physical, mental, and social well-being of the community.

Vision: Codman Square Health Center is our community’s first choice for comprehensive, holistic, and integrated services, and empowers individuals to lead healthy lives and build thriving communities.

Values: Patients Our patients are the center of our care team.

Community The well-being of the individual is deeply connected to the health of the community.

Advocacy We advocate for responsive policies and resources to address health disparities and promote health equity.

Staff We are a diverse, empowered, compassionate, and prepared workforce.

Innovation We promote a culture of innovation that has measurable and sustainable impact.

Partnership We build and sustain diverse partnerships.

Codman Square Health Center is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, sex, color,

religion, national origin, sexual orientation, protected veteran status, or on the basis of disability.