RN Care Manager

Summary

Join Boston Health Care for the Homeless Program (BHCHP) as a Nurse Care Manager and make a real difference in the lives of vulnerable individuals experiencing homelessness. This full-time position offers a hybrid work model, combining on-site and remote work. You will be responsible for creating and implementing person-centered care plans for a panel of patients, collaborating with a multidisciplinary team. The role involves outreach to various settings, including home visits and hospital visits, to provide both preventative and reactionary services. You will connect enrollees to supportive services and resources, participate in quality improvement efforts, and use data to evaluate outcomes. This position is ideal for those passionate about addressing social determinants of health and systemic inequities.

Requirements

• Licensed as Registered Nurse in the Commonwealth of Massachusetts
• Nursing experience with complex patients preferred; BSN preferred but not required
• Experience working with vulnerable populations, including people with a history of trauma, those experiencing socioeconomic stress, homelessness, or substance use disorders
• Experience working on cross-disciplinary, integrated teams; strong interpersonal skills and clinical problem solving
• Comfort with working in an autonomous clinical and outreach setting; capable of working with data to track and measure performance
• Computer skills: Proficient with Microsoft Excel Spreadsheets, entering narrative and other data into a database, Epic EHR
• Flexibility and strong multitasking skills

Responsibilities

• Enact essential duties through a mix of onsite and remote days a week
• Provide clinical assistance to 3-5 Care Coordinators with panels of approximately 50 patients each, in addition to a small panel independently managed of approximately 5 clients. This includes chronic disease management and medication support
• Engage vulnerable populations as part of a multidisciplinary outreach team. This includes home visits, outreach to hospitals, homeless shelters, and other settings, as needed
• Perform timely follow up and medication support following transitions of care
• Connect enrollees to various needed supportive services and resources
• Provide clinical oversight and tracking for annual comprehensive health assessments
• Participate in developing patient-centered care plans and reviewing health assessments for the BH CP enrollees on their panel
• Work with BHCHP staff at Boston-area hospitals to coordinate hospital admission/discharge plans with the behavioral health clinician, PCP, ACO, MCO etc
• Use data to evaluate outcomes of targeted interventions for panel. Assist in developing appropriate adjustments to care plans based on this data
• Implement prevention & engagement strategies in collusion with Care Coordinator
• Provide health coaching for groups of enrollees or individual enrollees as needed
• Support connection to substance use treatment and affiliated services when appropriate
• Engage in quality improvement efforts, as led by the BH CP Clinical Team Coordinator and Clinical Program Manager

Preferred Qualifications

Bilingual skills in Spanish and English strongly preferred

Benefits

• $4,000 Sign-on Bonus
• The compensation starts at $40.00 and increases based on years of experience
• 4 weeks’ vacation
• Health, dental and vision insurance
• 403B retirement savings plan and employer retirement contribution
• Pre-tax MBTA pass program with 40% discount
• Yearly increases
• Additional compensation of seven thousand five hundred dollars added to your base hiring rate for demonstrated bilingual proficiency
• The opportunity to work with local hospitals and community health centers