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Complex Care Manager Ambulatory

Company: Cambridge Health Alliance
Location: Cambridge
Posted on: July 16, 2021

Job Description:

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.

Work Experience:

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 Massachusetts

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 desirable.


Keywords: Cambridge Health Alliance, Cambridge , Complex Care Manager Ambulatory, Other , Cambridge, Massachusetts

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