Community Care Cooperative (C3) is a new, 501(c)(3) not-for-profit, Accountable Care Organization (ACO) governed by FQHCs. Our mission is to leverage the collective strengths of Federally Qualified Health Centers (FQHC) to improve the health and wellness of the people we serve.
The Nurse Care Manager will be responsible for performing comprehensive assessments and care planning for health center patients who have been identified for the MassHealth Long Term Services and Supports Community Partner (LTSS CP) Program. The individual in this role will work directly with health center patients and ensure that the patient's medical, behavioral, and social service needs are assessed, and a plan of care is in place. The Nurse Care Manager will be responsible for collaborating closely with the Patient's primary care team and the assigned LTSS CP provider. This position is a centralized resource who will support multiple health centers teams.
- Perform comprehensive assessments and care plans for patients assigned to LTSS CP supports.
- Collaborate and coordinate with the LTSS CP provider to promote patient engagement
- Maintain communication through face-to-face, telephonic, and/or digital contact with the patient's health center care team
- Though the case management is primarily telephonic, may also perform face to face outreach with the patient either at the health center or some other community-based location
- Understand and adhere to contractual requirements as it relates to the MassHealth community partner program
- Develop excellent relationships with LTSS CP providers
- Provide insight and recommendations to promote internal and external process improvements
- Maintain accurate, timely documentation in electronic systems
- Maintain confidentiality of client and employee information
- Function as a clinical resource and perform triage for member calls that may come to C3's Member Advocate team
- Minimum of a BSN degree or ASN + relevant experience and current Massachusetts RN license
- 2+ years case management experience
- Experienced working with patients who have complex medical, behavioral and social needs
- Excellent organizational and time management skills
- The proven ability to work independently
- Experienced in engaging patients telephonically and/or in community-based settings
- Able to prioritize and flexibly manage a variable workload
- Excellent oral and written communication skills
- Experience and proficiency with Microsoft Office and online record keeping
- A valid driver's license and provision of a working vehicle
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Associated topics: ambulatory, asn, cardiothoracic, mhb, psychiatric, recovery, registered nurse, staff nurse, surgery, transitional