care manager

Volunteer Behavioral Health Care System

Care Manager (Full-Time) &ndash; Cookeville CampusLocation: Cookeville, TN Schedule: Monday to Friday 8am-5pmEducation Required: Bachelor&rsquo;s degree in counseling, psychology, social work, behavioral sciences, or related field.Salary scale based on experience.Job SummaryWe are hiring a full-time Care Manager to provide person-centered support to adults and children. This role helps individuals access medical, behavioral health, social, and community resources following the TN Health Link model. Services are delivered in the office and community.Key ResponsibilitiesDevelop and monitor individualized care plans.Coordinate medical and behavioral health appointments.Connect individuals to community resources (housing, food, employment, legal, etc.).Provide in-person support for treatment and medication adherence.Assist with hospital discharge planning and crisis support.Educate patients and families on independent living skills.Maintain accurate documentation and reports.Work collaboratively with team members, families, and providers.QualificationsBachelor&rsquo;s degree behavioral sciences required (Counseling, Psychology, Social Work, or another related health field).Strong communication, organizational, and interpersonal skills.Ability to work both independently and as part of a multidisciplinary team.Must demonstrate empathy, professionalism, and reliability.Why Join Us?Meaningful work that impacts individuals and families in the community.Supportive team environment.Opportunities for professional growth.Competitive benefits and full-time stability.Job Type: Full-timeBenefits:<ul><li>401(k)</li><li>401(k) matching</li><li>Dental insurance</li><li>Employee assistance program</li><li>Health insurance</li><li>Health savings account</li><li>Life insurance</li><li>Loan forgiveness</li><li>Paid time off</li><li>Professional development assistance</li><li>Vision insurance</li></ul>Application Question(s):<ul><li>Do you have a bachelor&rsquo;s degree in behavioral sciences (Counseling, Psychology, Social Work, or another related health field)?</li></ul>Education:<ul><li>Bachelor's (Required)</li></ul>Experience:<ul><li>Case management: 1 year (Required)</li></ul>Work Location: In person

Care Manager

Lao Family Community Development

<div><div><div><div><div><div><div><div><div><div>Lao Family Community Development, Inc. (LFCD) is a community development non-profit agency established in the City of Richmond in Contra Costa County in 1980. Today, the Lao Family has expanded its operations and service footprint to three additional counties, including Alameda, Sacramento, and Yolo. LFCD&rsquo;s headquarters office is in Oakland, CA. It delivers programs and services from 7 locations in 35 languages. The agency provides both community development real estate facilities and a diverse array of workforce, education, and human services that directly support predominantly low-income US-born high-barrier families and individuals, refugees, immigrants, transitional age youth, seniors, and other special populations such as individuals with disabilities.
Job Summary: Reporting to the Lead Care Manager, the Care Manager provides direct services to members who enrolls in Cal AIM to which Molina Enhanced Care Management (ECM) and Community Supports (CS) services, including Health Net (CS) and Partnership (ECM) services.
The Care Manager supports unhoused, justice-involved, medically complex, and vulnerable populations by delivering trauma-informed, culturally responsive, and person-centered care coordination. Under supervision, this position conducts outreach and engagement, completes comprehensive assessments, develops individualized care plans, coordinates services across multiple systems, and assists participants in navigating complex medical, behavioral health, housing, and social service systems.
The Care Manager works collaboratively with Managed Care Plans (MCPs), healthcare providers, housing agencies, and community-based organizations (CBOs) to promote long-term health stability, housing placement, and self-sufficiency. This position will be primary stationed at the North Sacramento Office, however travel between LFCD offices in South Sacramento and Yolo County may be required as needed by the program. 
Roles and Responsibilities:<div><ul><li>
Conduct comprehensive health and social needs assessments under supervision and assist in developing individualized care plans.</li><li>
Provide direct case management services using trauma-informed, strengths-based, and culturally responsive approaches.</li><li>
Coordinate services across medical, behavioral health, housing, employment, and social service systems.</li><li>
Conduct outreach and engagement for individuals experiencing homelessness or at risk of housing instability.</li><li>
Assist participants with housing navigation, applications, documentation, and placement processes.</li><li>
Support landlord engagement efforts as directed by the Lead Care Manager.</li><li>
Maintain accurate, timely, and compliant documentation in accordance with CalAIM, Medi-Cal, HIPAA, MCP guidelines, and agency standards.</li><li>
Participate in case conferences, multidisciplinary meetings, and care coordination meetings with MCPs and community partners.</li><li>
Monitor participant progress and promptly report barriers, risks, or crises to the Lead Care Manager.</li><li>
Support data collection, tracking, and reporting to ensure compliance and performance outcomes.</li><li>
Respond appropriately to crises using de-escalation techniques and seek supervisory guidance when necessary.</li><li>
Adhere to agency policies, ethical standards, and evidence-based practices.</li></ul></div>
Requirements and Qualifications:<div><ul><li>
Bachelor&rsquo;s degree in Social Work, Psychology, Public Health, Human Services, or a related field; or equivalent combination of education and relevant experience.</li><li>
Minimum of 1&ndash;2 years of experience providing direct case management, care coordination, housing navigation, or social services to vulnerable populations.</li><li>
Experience working with unhoused individuals, justice-involved populations, individuals with complex medical or behavioral health conditions, or low-income communities preferred. Knowledge of trauma-informed care, strengths-based case management, and person-centered service planning.</li><li>
Bilingual in Spanish preferred.</li></ul></div><ul><li>
Self-starter, ability to work with minimal supervision; excellent communication, multi-tasking, community relations, networking, and public speaking skills.</li><li>
Demonstrated ability to work with families, women, and children without discrimination towards people of diverse cultures, races/ethnicities, socio-economic positions, ages, religions, genders, physical/mental challenges/disabilities, and sexual orientations.</li><li>
Understand, explain, and apply complex local, state, and federal regulations, policies, and procedures.</li><li>
Able to travel to meet with service providers and participants; ability to work independently as well as part of a team; must have a flexible schedule on evenings and weekends.</li><li>
Proficient computer skills in MS Word, Excel, PowerPoint, database management, and Internet Explorer.</li><li>
In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification form upon hire; must pass background check.</li><li>
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit and work on the computer; use hands to handle or feel and talk or hear; and move objects up to 25 pounds.</li></ul>
Compensation: Salary is based on experience and education, along with a comprehensive benefits package including health plan/vision, dental, paid vacations, holidays, sick leave, and employer-contributed pension/group life insurance.
To Apply: Submit your cover letter and resume. This position is open until filled and may be closed at any time.
Lao Family Community Development Inc. is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age (over 40), disability status, protected veteran status, or any other characteristic protected by law. LFCD is compliant with the Fair Chance to Compete for Jobs Act of 2019 and the Americans with Disabilities Act of 1990 (ADA).</div></div></div></div></div></div></div></div></div> 
Monday-Friday 8:30am-5pm</div>

CARE Manager

Emory Healthcare

<div>Overview:
<div>
Be inspired. Be valued. Belong.</div><div></div><div> 
At Emory Healthcare we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be. We provide:</div><ul><li>
Comprehensive health benefits that start day 1</li><li>
Student Loan Repayment Assistance &amp; Reimbursement Programs</li><li>
Family-focused benefits
</li><li>Wellness incentives</li></ul><div>
Ongoing mentorship, development, leadership programs...and more!</div>
Description:
<div>
The Care Manager is responsible for patient care coordination from admission through discharge; ensuring smooth transitions of care as the patient is discharged from the hospital setting, ensuring and facilitating high quality clinical and cost outcomes, procuring and securing post-acute services, coordinating and advocating for patients and families with both internal and external stakeholders, and identifying and addressing potential barriers to care coordination/discharge planning in an effort to foster efficient care delivery and maximize reimbursement. The Care Manager will begin the process of care coordination at the time of the patient's admission by completing a thorough admission assessment and/or psychosocial assessment which will allow for a timely and accurate capture of information as well as foster the ability to begin working towards a discharge plan. The Care Manager is an integral part of the interdisciplinary care team who is required to attend rounds, care conferences, and/or care team meetings. The Care Manager will act as a representative of both the hospital care team and the patient/family in an effort to balance patient/family choice and projected care coordination needs with the ability to execute such services. The Care Manager will work with the hospital care team and the patient/family in order to plan and implement the best possible plan for the patient while taking various factors, limitations, and patient/family preference into consideration. The Care Manager will identify and recommend post-acute services and will complete referrals to appropriate post-acute care providers in a timely manner, coordinating directly with the patient/family as well as the care team. Through continuous assessment and review, the Care Manager will apply critical thinking to ensure alignment and appropriateness of post acute services as the patient clinically progresses throughout their stay. Ultimately, the Care Manager is responsible for ensuring the discharge plan is aligned to be executed with the patient's medically cleared for discharge date as well as the projected length of stay as provided by the payor. The Care Manager identifies and participates in the development of strategies to reduce unnecessary length of stay and/or resource consumption. The Care Manager escalates cases, as appropriate, to management, Physician Advisor, Complex Care team and/or Ethics committee. It is the role of the Care Manager to educate patients/families as well as the care team as it relates to post acute services, transitions of care, readmission mitigation, appropriate post-acute level of care choices and available resources. The Care Manager provides supportive and therapeutic communication for patients, families and loved ones who are experiencing anxiety or stress due to illness, injury or physical limitations. The Care Manager must communicate confidently, effectively, and therapeutically while being assertive and conveying an impression which reflects favorably upon the organization The Care Manager will initiate and facilitate discussions with the payors in order to act as an advocate on behalf of the patient and hospital in an effort to reduce non-covered, non-authorized, or denied services. The Care Manager will issue and administer notices of non-coverage and potential liability to patients in accordance with predetermined regulations, policies, and procedures. The Care Manager serves as a resource to the Physician, Interdisciplinary Care Team, and patient for the interpretation of external regulations and organizational policies and procedures as it pertains to Discharge Planning and Care Coordination. The Care Manager will ensure compliance with all regulatory requirements as it relates to Government and Commercial Payors. The Care Manager will ensure compliance with all third party payers and federal and state regulatory agencies. The Care Manager will ensure proper use of Case Management Systems and workflows.</div><div></div><div> 
Minimum Qualifications:</div><div>
RN CM: MINIMUM REQUIRMENTS 1. Valid, unencumbered Registered Nurse License approved by the Georgia Board of Nursing. 2. Two (2) years experience in healthcare. PREFERRED 1. Bachelors degree in Nursing from an accredited school of nursing.</div><div>
SW CM I: MINIMUM REQUIREMENTS 1. Masters in Social Work from an accredited school of social work. 2. Demonstrated knowledge of software/EMR applications.</div><div>
PREFERRED 1. One (1) year healthcare experience in Acute Care setting. 2. Accredited Case Manager (ACM) Certification through the American Case Management Association or Certified Case Management (CCM) through the Commission for Case Manager Certification.</div><div></div><div> 
SW CM II: MINIMUM REQUIREMENTS 1. Masters in Social Work from an accredited school of social work. 2. Licensed as a Master Social Worker (LMSW) through the Georgia Composite Board of Professional Counselors, Social Workers, and Marriage &amp; Family Therapists. 3. Demonstrated knowledge of software/EMR applications.</div><div>
PREFERRED 1. Two (2) years healthcare experience in Acute Care setting. 2. Accredited Case Manager (ACM) Certification through the American Case Management Association or Certified Case Management (CCM) through the Commission for Case Manager Certification.</div><div></div><div> 
SW CM III: MINIMUM REQUIREMENTS 1. Masters in Social Work from an accredited school of social work. 2. Licensed as a Clinical Social Worker (LCSW) through the Georgia Composite Board of Professional Counselors, Social Workers, and Marriage &amp; Family Therapists. 3. Demonstrated knowledge of software/EMR applications</div><div>
PREFERRED 1. Three (3) years healthcare experience in Acute Care setting. 2. Accredited Case Manager (ACM) Certification through the American Case Management Association or Certified Case Management (CCM) through the Commission for Case Manager Certification. productivity expectations and successfully complete yearly competencies.</div><div></div><div> 
JOIN OUR TEAM TODAY! Emory Healthcare (EHC), part of Emory University (EUV), is the most comprehensive academic health system in Georgia and the first and only in Georgia with a Magnet&reg; designated ambulatory practice. We are made up of 11 hospitals-4 Magnet&reg; designated, the Emory Clinic, and more than 425 provider locations. The Emory Healthcare Network, established in 2011, is the largest clinically integrated network in Georgia, with more than 3,450 physicians concentrating in 70 different subspecialties.</div>
Additional Details:
<div>
Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.</div><div></div><div> 
Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcare&rsquo;s Human Resources at careers@emoryhealthcare.org. Please note that one week's advance notice is preferred.</div></div>

Care Manager IP

AllHealth Choice

Role OverviewThe Care Manager (LPN) will work under the direct supervision of the Chief Nursing OfficerUnder general supervision and medical oversight, the Care Manager is a licensed clinician responsible for their populations health management to improve individual overall health, reduce risk for significant events, and reduce claims utilization. The Care Manager will focus on relationship building with their members, to establish shared goals and care action plans, identify care gaps, and encourage and coordinate preventative and maintenance care measures, including healthy lifestyle behaviors. The Care Manager will also work with our Enrollment Team to get new members enrolled and onboarded. This is a hybrid position- some remote work and some office work.Key Responsibilities&middot; Shift flexibility required, including evenings, weekend, and holiday work based on business need. Must be able to work independently and be self- motivated. Exceptional assessment skills are essential.&middot; Travel may be required.&middot; Develops rapport with member to establish health and wellness goals and provide custom education, based on level of readiness, biometric data, and health assessment results.&middot; Utilizes assessment skills, health assessment, and claims data to identify preventative and maintenance care gaps and follows Care Paths to develop a Care Action Plan specific to the chronic disease.&middot; Educates and encourages healthy lifestyle behaviors that will improve overall member health.&middot; Triages calls and requests from clients, families, and care givers according to established procedures and coordinates care with providers, other internal departments, and outside agencies.&middot; Provide clinical and basic technical support for telehealth devices and platform.&middot; Coordinates care for an inter-professional, multi-disciplinary approach with providers, pharmacist, registered dieticians, disease-specific experts, and support departments as appropriate, both internal and external.&middot; Effectively communicate with members and families in diverse cultural and age groups to discern deviations/changes in client's condition and activate appropriate measures based on Care Paths, including engaging and referring to providers.&middot; Engages clients through motivational interviewing and health coaching techniques to evoke change behaviors according to approved Care Pathways, company policies and procedures, and standard nursing practice guidelines.&middot; Advocates as a contact person for client, family, healthcare team members, and outside agencies to assure continuity of care and optimal clinical and resource outcomes.&middot; Documents the course of care and all communications in appropriate instances according company policies and procedures.&middot; Adheres to all other company policies and procedures.&middot; Adherence to and compliance with Information Systems security policies and procedures and attends all Information Systems security trainings. Reports information systems security problems according to company policy and as appropriate.&middot; Demonstrates and articulates clear understanding of AHC product offerings, applications, and client differences. Provides clinical support based on assigned level of care, and client specific processes.&middot; Participates in routine productivity and performance reviews, revising workflows as indicated and appropriate.&middot; Must be able to work independently and be self- motivated. Exceptional assessment skills are essential.&middot; Remote working is allowed. A space should be available that allows for absolutely no distractions. Mandatory office days will be required.&middot; Must successfully pass the company technical skills assessment.&middot; Performs other duties as assigned$1000.00 signing bonus after completion of 90 day introductory period.Required Skills and QualificationsEducation/Licensing/Certification:&middot; Current State License and Multistate License as a Licensed Vocational Nurse or Licensed Practical Nurse&middot; Must remain in good standing to be eligible for other state licenses&middot; Must not be on the Medicare OIG exclusion list, verified annually&middot; Current State Driver&rsquo;s LicenseRequired Experience:&middot; Experience in clinical assessment and triage.&middot; EMR (Electronic Medical Record) experience.Knowledge, Skills, and Behavioral Competencies:&middot; Accountability, Optimization, and Execution- Juggles many priorities and competing demands for one's time.- Acts resourcefully to ensure that work is completed within specified time and quality parameters.- Removes obstacles to move the work forward and/or get efforts back on track.- Surfaces problems and issues before projects get derailed.- Demonstrates a &quot;can-do&quot; spirit, a sense of optimism, ownership, and commitment.&middot; Maintains a consistent, high level of productivity.&middot; Takes personal responsibility to make decisions and act.&middot; Does not easily give up in the face of unexpected obstacles.&middot; Projects a positive image and serves as a role model for others&middot; Effective written and oral communications&middot; Proficiency with Microsoft office programs&middot; Maintains proficiency in AHC applicationsJob Type: Full-timePay: From $21.00 per hourBenefits:<ul><li>401(k) matching</li><li>Dental insurance</li><li>Health insurance</li><li>Life insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Work Location: Hybrid remote in Tifton, GA 31794

Care Manager (LPN)

Titanium Healthcare

<div>WE ARE TITANIUM HEALTHCARE

Titanium is a healthcare company that puts heart and compassion above all else. Millions of Americans just aren&rsquo;t getting the medical care they need. We&rsquo;re on a mission to change that. For patients that means exceptional support and better care. For providers it means better support and time to focus on patients, and for partners that means higher quality and lower cost. 
Join us in our mission! 
POSITION SUMMARY

The RN Care Manager is an essential part of the ECM team. Enhanced Care management (ECM) is funded through California Advancing and Innovating Medi- Cal (CalAIM) and are programs that coordinate care by utilizing a person-centered approach to maximizing an individual&rsquo;s health and life trajectory. ECM services are medically appropriate, and cost-effective alternatives to services covered under the state plan. Titanium outreaches and engages to promote services, enroll members in the ECM program, and provide services intended to improve social and physical determinants of health. Members remain in the ECM programs until they no longer need or decline services. ECM services consist of a care team providing in-person care management and care coordination that aims to ensure services are available from managed care providers for members who are frequent utilizers of health services and individuals experiencing homelessness. The program is designed to leverage existing community care management, sustainability, housing transition, navigation, infrastructure, and experience. 


WHERE YOU&rsquo;LL WORK

This position is remote and is based out of California. Standard business hours are Monday through Friday from 8:00 am to 5:00 pm. 


WHAT YOU&rsquo;LL DO
<ul>
<li>Facilitate access to primary care and behavioral health providers, as needed</li>
<li>Responsible for working effectively with and as part of Titanium&rsquo;s interdisciplinary team to provide high quality and effective care management to members</li>
<li>Engage members in skilled therapeutic interactions to promote health behaviors and/or other behavioral health interventions within scope of practice</li>
<li>Coordinate care using resource linkage and partnering with other professionals and organizations in the community to ensure quality of care for members</li>
<li>Provide seamless transition of care that meets requirements for post ER visits and hospitalizations</li>
<li>Complete regularly scheduled follow-up visits</li>
<li>Provide care coordination through phone calls, emails, messages, updating calendars, scheduling appointments, data entry, and attending meetings</li>
<li>Support the Behavioral Health Care Manager, Community Health Worker, and Care Coordinator with delegated tasks</li>
<li>Collaborate on member care issues with other ECM care team members</li>
<li>Participate in weekly systematic case reviews and ad hoc case reviews</li>
<li>Consult with the Clinical Nurse Leader and/or the Behavioral Health Care Manager before taking any clinical action</li>
<li>Strategize to engage members in care and conduct motivational interviews</li>
<li>Provide health education to members within scope of practice</li>
<li>Initiate a care plan and complete all necessary assessments of healthcare plan guidelines</li>
<li>Understand and abide by all departmental and companywide policies and procedures</li>
<li>Perform other duties and projects assigned</li></ul> 


WHO YOU ARE

Sensory Requirements
<ul>
<li>Fluent in English (written and verbal)</li>
<li>Ability to communicate clearly in-person, by phone, and electronically</li>
<li>Adequate hearing and vision (with corrective devices if necessary) to conduct assessments and documentation</li>
<li>Ability to identify problems and use logic and related information to develop and implement solutions</li>
<li>Excellent organizational skills and attention to detail</li>
<li>Commitment to maintaining patient confidentiality and adhering to ethical standards in healthcare practice</li>
</ul>
 Physical Activity
<ul>
<li>Must be able to remain in a stationary position</li>
</ul>
 Environmental Conditions
<ul>
<li>Ability to maintain professionalism</li>
<li>Ability to work independently and carry out assignments to completion within the parameters of established policies and procedures</li>
</ul>
 Technology Use
<ul>
<li>Frequent use of computers, keyboard, and handheld/mobile devices</li>
<li>Ability to type for extended periods</li>
<li>Competent with computers, email, virtual platforms, and Microsoft Office based programs</li></ul> 


WHAT YOU&rsquo;LL NEED
<ul>
<li>Associate&rsquo;s degree in nursing</li>
<li>Minimum 1+ years of experience as an RN working in a healthcare setting, such as a medical clinic or acute care hospital</li>
<li>A current and unrestricted CA state RN license</li>
<li>Experience using an EHR/EPM</li>
<li>Distraction-free home workspace with a secure internet connection</li></ul> 


NICE TO HAVES
<ul>
<li>Care management experience preferred</li>
<li>Bachelor's degree in nursing</li>
<li>Experience using eClinical Works (eCW)</li>
<li>Valid BLS certification from the American Heart Association</li>
<li>Valid CPR Certification</li>
<li>Bilingual in Spanish</li></ul> 


WHAT YOU&rsquo;LL ENJOY
<ul>
<li>Make an impact: an organization who cares about its employees, communities, and the future of healthcare</li>
<li>Inclusivity: be a part of a workplace where you not only belong but also can be the best version of yourself</li>
<li>Growth: opportunities to develop and grow your career with us</li>
<li>Community: you are encouraged to have a voice, share your opinions, and have an individual impact on the business</li>
<li>Paid Time Off: 12 holidays and up to 15 days of accrued PTO to rest and recharge plus additional time for sick, jury duty, bereavement, reproductive loss, and therapy</li>
<li>Work Life Balance: enjoy flexibility to maximize your well-being and success with our hybrid work model</li>
<li>Medical, Dental, &amp; Vision Benefits: we cover up to 100% of your premium and 50% of your dependents depending on the plan</li>
<li>Prioritize your mental health with unlimited therapy sessions funded 100% by Titanium Healthcare</li>
<li>Flexible Spending, Health Savings &amp; Dependent Care Accounts</li>
<li>Life/AD&amp;D insurance funded 100% by Titanium Healthcare</li>
<li>Supplemental Short-Term Disability</li>
<li>Employee Assistance Programs</li>
<li>Protect your pet(s) with Pet Insurance</li>
<li>401(k) plan</li></ul> 


EEO Statement

At Titanium Healthcare, our mission is to fearlessly reengineer the way healthcare works to reduce costs, ensure better outcomes, and provide everyone, everywhere, with the kind of compassionate and coordinated care they deserve. We believe that achieving this mission starts with a diverse and inclusive workforce. 


Titanium Healthcare is an equal opportunity employer. We are committed to promoting and celebrating all backgrounds and encourage all applicants, regardless of race, religion, gender, sexual orientation, disability, age, marital status, parental status, military or veteran status, or any other legally protected status, to apply. We believe that diversity and inclusion drive innovation and equity in healthcare, enabling us to better serve our communities and make a lasting impact.</div>

RN Care Manager

<div>Summary / Objective: 
The Care Manager, RN acts in a non-caregiver capacity by facilitating coordination and communication between all members of the health care team in the decision making process to minimize fragmentation of the health care delivery system. As a member of the Care Management Department, this position is responsible for contributing to the standards of quality and service expected by both external and internal stakeholders, including ensuring accurate information flows to interdepartmental teams, proper documentation and adherence to standards related to case management activities.
<div>
Essential Functions: 
<ul><li>Exceed physician, provider and member expectations by providing professional and personalized service at all times.</li><li>Is aware of and continually supports strategic plans that ensure company objectives and goals are obtained.</li><li>Attends collaborative meetings with both internally and externally healthcare team members to support management services for clients served.</li><li>Builds and leverages cross-functional collaborative relationships to facilitate a team-work oriented atmosphere.</li><li>Assess clients for care management services after a referral has been made based on the admission screening and referrals for potential patient issues.</li><li>Develop and manage a coordinated plan of care to meet client and/or family needs</li><li>Assure that clients are placed on appropriate self-management plan and protocols, individualizes client care needs through consultation with the multidisciplinary team.</li><li>Coordinates services to support the appropriate care needs to promote best client outcomes and efficient use of healthcare resources.</li><li>Works with clients and providers to enhance the quality of client management and satisfaction.</li><li>Performs appropriate assessments and develops client-directed care plans within health plan required timeframes and per NCQA standards.</li><li>Assess need to involve medical director or primary care team when appropriate to assist with development of client-directed plan of care.</li><li>Regularly reviews and updates care plans for continuity of care and facilitates plan modifications including barriers to goals.</li><li>Coordinates with Non-Licensed Care Navigators to ensure appropriate follow-up with high risk clients to address identified goals and barriers.</li><li>Documents all interventions and telephone encounters with providers, members and vendors in accordance with established documentation standards.</li><li>Provide comprehensive training for new employees</li><li>Continues own education by keeping his/her knowledge current and conducts independent research of commercial plan guidelines to strengthen general understanding of state and federal resources to support position responsibilities.</li><li>Ensures compliance with departmental and PSW policies and procedures, with special emphasis on compliance with HIPAA privacy and security requirements and all state, federal and plan regulatory mandates.</li><li>Provides Transitional Care Management services post discharge from emergency room, acute inpatient or post-acute inpatient stays.</li><li>Follows Eric Coleman&rsquo;s Pillars of Transitional Care to support reduced risk of adverse events following discharge.</li><li>Provides education on seeking medical attentional early or using urgent care services when appropriate versus an emergency room.</li><li>Follows the standards of care management services as outlined in the guideline manual updated no less than annually.</li><li>Provides telephonic engagements to clients on worklist to meet standards of engagement to include both timing, frequency, and duration of engagements.</li></ul></div>
<div>
Knowledge/Skills/Abilities: 
<ul><li>Set a positive example by displaying a pleasant and approachable demeanor and remaining friendly and courteous at all times.</li><li>Proactive team player, strong follow through, quick decision making abilities and ability to problem solve.</li><li>Interpersonal skills, with the ability to build strong relationships at all levels.</li><li>Strong verbal and written communication skills with customers, supervisors and co-workers.</li><li>Strong organizational, time management and prioritization skills:</li><li>Self-starter. Ability to set priorities and keep to projected schedules.</li><li>Excellent computer proficiency (MS Office &ndash; Word, Excel, Outlook ) including being able to effectively maintain written and computer records in accordance with regulatory agencies.</li><li>Familiarization and experience with Electronic Health Record systems</li></ul></div><div>
Required Education and/or Work Experience: 
<ul><li>Three (3) years of full proficiency clinical experience.</li><li>Verifiable experience or knowledge of a variety of clinical areas of medical treatment as related to general population and pediatric needs.</li><li>Knowledge and experience in providing care management and/or transitional care management services</li></ul></div>
<div>
Preferred Education and/or Work Experience: 
<ul><li>Bachelor&rsquo;s degree from accredited school of nursing.</li><li>Case Manager Certification.</li><li>Experience with commercial health plans.</li></ul></div>
<div>
Required Certificates, Licenses and Registrations: 
<ul><li>Nursing degree (ie: RN)</li><li>Active unrestricted state license in State of Washington.</li></ul></div> 


*PSW does not typically hire at the top of the pay range *
Benefits:
<ul><li>
401(k)</li><li>
401(k) matching</li><li>
Dental insurance</li><li>
Disability insurance</li><li>
Flexible Spending Account (FSA)</li><li>
Health Savings Account (HSA)</li><li>
Health insurance</li><li>
Life insurance</li><li>
Paid time off</li><li>
Tuition reimbursement</li><li>
Vision insurance</li></ul></div>

Care Manager, RN

Charles River Community Health

<div>Nurse Care Manager
CLASSIFICATION/STATUS: Non-exempt, Licensed, Full Time, Permanent
IMMEDIATE SUPERVISOR: Lead Nurse Care Manager
SUPERVISORY RESPONSIBILITIES: None
LOCATION: Hybrid (80% on-site, 20% remote)
SALARY: Band E ($34.50 - $45.00/hour)
WHO YOU ARE:
YOUR ROLE &amp; 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 the comprehensive, integrated, and equitable primary healthcare that matters most to them. As an integral member of the care management team, the Nurse Care Manager will have the opportunity to make a profound impact on the lives of people living with complex and/ or chronic conditions, many of whom also face multiple barriers in their lives which make it difficult for them to achieve the self-care required to improve their health and well-being.
The ideal Nurse Care Manager candidate is someone who will be able to:
<ul><li>Champion Patient Success: Serve as the dedicated Care Manager for a patient panel, building long-term, trusting relationships to drive better health outcomes.
</li></ul><ul><li>Bring Goals to Life: Update and maintain holistic care plans that reflect the &quot;whole person,&quot; ensuring medical strategies align with what matters most to each individual.
</li></ul><ul><li>Lead Care Integration: Facilitate high-level care coordination, connecting patients with the right resources both within CRCH and across the broader healthcare landscape.
</li></ul>This position requires flexibility and may vary from day-to-day to meet members where they are. Outreach methods may vary based on the needs of the organization and may include telephone or in-person in a variety of settings, including the health center, community, home, or an inpatient facility.
YOUR RESPONSIBILITIES
<ul><li>Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with primary care providers.</li>
<li>Meet the patient where he/she is; observe the patient without intervention or judgment.</li>
<li>Has knowledge of common chronic medical conditions presented in the population served and is able to:
<ul><li>Educate the patient on their medication conditions and medications, and build their self-management skills;</li>
<li>Use motivational interviewing to promote behavioral change.</li>
<li>Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.</li>
</ul></li><li>Conduct medication reconciliation in conjunction with the clinical pharmacist.</li>
<li>Engage members and caregivers in active care planning with a focus on medical, behavioral, social, member-centered care needs. Coach and guide member/representative to meet bio/psycho/social goals.</li>
<li>Provide care coordination, which may include but is not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up.</li>
<li>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.</li>
<li>Meet regularly with medical directors and nurse care managers, and speak as needed with Primary Care, ED, and inpatient to triage program issues appropriately when patients are discharged from hospitals.</li>
<li>Participate in local site operations, including team meetings.</li>
<li>Actively participate in planning and growth of the program as needed, to respond to evolving needs of Mass Health ACO. Maximize the use of ACO care management tools and technology to ensure that work is comprehensive, detailed, automated and streamlined to the extent possible. Make recommendations to change workflows to enhance the ease of use, practicality, and effectiveness of the ACO tools and processes.</li>
<li>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.</li>
<li>Facilitate interdisciplinary consultation on patient's behalf through participation in rounds, team meetings, and clinical reviews.</li>
<li>Establish and comply with quality metrics for performance and adhere to documentation and work flow standards.</li>
<li>Maintain HIPAA standards and confidentiality of protected health information.</li>
<li>Adhere to departmental/organizational policies and procedures.</li>
<li>Provide assistance in seasonal influenza/COVID vaccination efforts when applicable.</li>
<li>Participate in the integrated care team meetings and rounds as required.</li>
<li>Maintain accurate, timely documentation in electronic systems including health center EHRs.</li>
<li>Provide coverage for team members who are out of office.</li>
<li>Serve as the point person for enrollees coming out of the Transitions in Care Program and moving into Care Management. Take all needed steps that this process is seamless for care team members and the enrollee, family, and caregivers.</li>
<li>Ensure that all care management is offered in a culturally and linguistically-appropriate manner and with disability competence.</li>
<li>Ensure that all necessary accommodations are consistently made for members with disabilities.</li>
<li>Promote a sense of teamwork through demonstration of self-direction and self-motivation. Solve problems independently or know when to seek consultation.</li>
<li>When onsite, co-locate near the medical nursing and provider teams for teambuilding.</li>
<li>Perform other duties as assigned by the Lead Nurse Care Manager or designee.</li>
</ul>
YOUR QUALIFICATIONS, COMPETENCIES, TRAITS
<ul><li>Bachelor of Science degree in nursing required.</li>
<li>Must be licensed in Massachusetts as a Registered Nurse</li>
<li>Experience in nursing with recent clinical experience in outpatient medical setting or other related outpatient practice preferred.</li>
<li>Must have demonstrated solid interpersonal, communication, and management skills.</li>
<li>Must be able to continually update clinical knowledge and skills through formal and informal education and review of current literature.</li>
<li>Must have knowledge of ambulatory and clinical practices, workflows, and operations.</li>
<li>Must work well independently, have sound decision making skills, and work effectively with and through inter-professional colleagues when required to make and facilitate complex decisions.</li>
<li>Must exercise a high degree of professional judgment within the scope of licensure.</li>
<li>Experience working with historically underserved populations preferred.</li>
<li>Bilingual (Spanish, Portuguese, or Haitian Creole) strongly preferred.</li>
<li>Experience with Patient Centered Medical Home model and concepts preferred.</li>
<li>Must have a willingness to work flexible hours to meet the organization's needs/demands.</li>
<li>Must be able to travel to either Charles River Community Health site (Brighton and Waltham) as needed.</li>
<li>Must have excellent communication skills, particularly with people from diverse cultures whose primary language is not English, with the ability to understand the community, population, and patients we serve.</li>
<li>Must believe in the work we do at CRCH, with a strong passion to serve underserved populations in diverse settings.</li>
</ul>
WHO WE ARE &amp; WHAT WE DO
Charles River Community Health&rsquo;s mission is to partner with individuals and families so they can thrive and lead healthier lives by delivering the 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, and 90% of those served are low income, while over 70% need services in a language other than English.
We are committed to providing patients with timely access to the right care, at the right place and at the right time, collaborating with other organizations to connect patients with a comprehensive range of services and provide continuity of care, and creating new community partnerships to meet the changing needs of patients and the community.
We value caring for everyone with dignity, respect, and compassion, reducing cultural, financial and other barriers to care, and eliminating health care disparities for our patients. 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 Nurse Care Manager rewarding and impactful! You will be part of a dynamic and fast-paced team with a shared vision to break down barriers in delivering healthcare excellence!
OUR BENEFITS &amp; PERKS
Medical &amp; Dental Insurance
Short &amp; 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 and similarities. By providing and supporting a work culture that fosters and builds upon diversity and its strengths, CRCH will better serve our local communities and continue to provide quality patient care and services. CRCH is an employment at-will organization and an equal opportunity employer committed to maintaining a work and learning environment free from discrimination on the basis of sex, race, color, religion, national origin, pregnancy, gender identity, sexual orientation, marital/civil union status, ancestry, place of birth, age, citizenship status, veteran status, political affiliation, genetic information or disability, as defined and required by state and federal laws. Additionally, CRCH prohibits retaliation against an applicant or employee because he or she has engaged in protected activity under the statutes prohibiting discrimination in the workplace.</div>

Nurse Care Manager

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