Lead Chronic Care Nurse

CLASSIFICATION/STATUS: Exempt, Licensed, Permanent, Full Time (40 hours/week)

IMMEDIATE SUPERVISOR: Associate Director of Nursing

SUPERVISORY RESPONSIBILITIES: Chronic Care RNs

PAY RANGE: Band E ($69,700 - $91,500 annual)

WHO YOU ARE:?

YOUR ROLE & 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 part of integral member of the care management team at CRCH, the Lead Chronic Care Nurse 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 makes it difficult for them to achieve the self-care required to improve their health and well-being.

The Lead Chronic Care Nurse works with primary care providers, pharmacists, behavioral health providers, community health workers, and nurses to identify and engage patients in care management with a focus on patient experience, improving health, and reducing cost. This role is responsible for working with patients to identify strengths and barriers and to develop an individualized, patient-centered care plan. Strong interpersonal skills, clinical expertise in chronic conditions prevalent in the CRCH population (i.e., Substance Use Disorder, Serious Mental Illness, Congestive Heart Failure, COVID, diabetes), patient engagement skills, and the ability to work both independently and collaboratively are key requirements for this role. The Lead Chronic Care Nurse will proactively seek out opportunities to care for patients, including during primary care visits, during ED outpatient visits, out in the community, or on the phone.

YOUR RESPONSIBILITIES

• Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with primary care providers.
• Meet the patient where they are and observe without intervention or judgment.
• Educate patients on their conditions and medications and build their self-management skills.
• Use motivational interviewing to promote behavioral change.
• Assess, triage, and rapidly respond to clinical changes that, if unaddressed, could necessitate emergency services.
• Conduct medication reconciliation with support of Clinical Pharmacist.
• Engage members and caregivers in active care planning with focus on medical, behavioral, social, member-centered care needs. Coach and guide member/representative to meet bio/psycho/social goals.
• Provide care coordination, which may include but not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up.
• Delegate assignments to Community Health Workers and/or Patient Navigators or Social Workers and follows up on completion. Consistently available for timely consult regarding patient matters during business hours.
• Assist with onboarding curriculum in collaboration with the Associate Director of Nursing.
• Meet regularly with medical directors, nurses, and care managers to triage program issues appropriately when patients are discharged from hospitals.
• Participate in local site operations, including team meetings
• Actively participate in planning and growth of program 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.
• 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.
• Maintain and review quality metrics with MassHealth ACO.
• Facilitate interdisciplinary consultation on patient's behalf through participation in rounds, team meetings and clinical reviews.
• Maintains HIPAA standards and confidentiality of protected health information.
• Adhere to departmental/organizational policies and procedures.
• Work with Compliance to assist with PCMH accreditation and ensuring program fits requirements.
• Assist and facilitate interviews for Chronic Care RN applicants.
• Participate in the integrated care team meetings and rounds as required.
• Maintain accurate, timely documentation in electronic systems including health center EHRs.
• Provide coverage for team members who are out of office
• Serve as the point person for enrollees coming out of the Transitions in Care Program and moving into CCM. Take all needed steps so that this process is seamless for care team members and the enrollee/family and caregivers.
• Ensure that all care management is offered in a culturally and linguistically appropriate manner and with disability competence.
• Ensure that all necessary accommodations are consistently made for membe rs with disabilities.
• Promote a sense of "teamwork” through demonstration of self-direction and self-motivation.
• Continually updates clinical knowledge and skills through formal and informal education and review of the current literature.
• Perform other duties as assigned by the Associate Director of Nursing or designee.

YOUR QUALIFICATIONS, COMPETENCIES, TRAITS?

• Bachelor of Science Degree in nursing required, Masters preferred.?
• Licensed in Massachusetts as a Registered Nurse with 3+ years of experience in nursing with recent clinical experience in outpatient medical setting.?
• Leadership experience preferred, including evaluation, performance management, and training.?
• Must have demonstrated interpersonal, solid communication, and management skills.?
• Willingness to support training needs for students, internships as requested.
• Must have knowledge of Ambulatory and clinical practices, workflows, and operations.
• 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.
• Excellent communication and strong team player.
• Must exercise a high degree of professional judgment within scope of licensure.
• Experience working with historically underserved populations preferred.?
• Excellent communication skills required, particularly when working with staff and patients from diverse cultures whose primary language is not English.?
• Experience with Patient Centered Medical Home model and concepts preferred.
• Must have a willingness to work flexible hours to meet the organization's needs/demands.
• Must be able to travel to either Charles River Community Health site (Brighton and Waltham) as needed.
• Must have excellent communication skills, particularly with people from diverse cultures, with the ability to understand the community, population, and patients we serve.
• Must have experience in diverse cultures, with strong commitment to promoting Diversity, Equity, and Inclusion and reducing inequities.
• Must believe in the work we do at CRCH, with a strong passion to serve underserved populations in diverse settings.

WHO WE ARE & WHAT WE DO?

Charles River Community Health’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 Lead Chronic Care Nurse 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 & PERKS?

Medical & Dental Insurance?

Short & 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.