The Complex Care Manager works as part of a complex care
management (CCM) team to screen high risk/high utilization
patients. Conducts comprehensive assessments of patients to
identify drivers of poor health outcomes and develop individualized
care management plan in collaboration with patient and care team.
Works with payers, caregivers and clinical staff to provide
goal-oriented, coordinated care and health management for
individual patients. Collaborates with staff at anchor site to
foster a meaningful and collaborative approach to health management
for identified patients. Provides leadership for a collaborative
multi-disciplinary team process by establishing a meeting agenda
and support for the team in care plan implementation for multiple
patients with complex medical, psychosocial, behavioral health
needs. Identifies and manages risk for specific populations, eg.
pts with COPD, unmanaged diabetes, heart failure, renal disease.
Contributes to an innovative, collaborative team process. This per
diem position will support the team during times of high volume,
vacancies, leaves and special projects.
Minimum of 5 years of broad clinical experience, predominately
in community health nursing, VNA or home care.
Extensive knowledge of chronic disease management.
Comfort working with patients with behavioral health and
substance abuse conditions and/or significant psychiatric
co-morbidities and patients requiring considerable support
accessing community-based supports.
Care Management Experience required.
Education/Training: Graduate of an NLN-accredited School of
Nursing, BSN required.
Licensure: Current RN license in the Commonwealth of
Certifications: American Heart Association BLS required
Demonstrated competency in managing a caseload of ethnically
diverse patients across the continuum of care.
Bi-lingual capacity (Spanish, Portuguese, Haitian Creole) highly