Complex Care Manager (RN)- HIV Services
Lowell, MA, United States On-site
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About the role
As a central member of the patients’ multidisciplinary heatlh care team, the Complex Care Manager (CCM) will be a Registered Nurse who identifies and engages patients with a focus on improving patient experience, improving health and reducing costs. Care management of complex patients is the deliberate organization of patient care activities to facilitate optimal delivery of health care services. Organizing care involves a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs. This is managed by the effective exchange of information among all participants on the care team, including the patient. Complex care management involves the oversight and coordination of care delivery targeted to high risk patients with diverse combinations of health, function and social problems. Excellent interpersonal skills, patient engagement skills and the ability to work indenpendently and collaboratively are key requirements of the role. Provide care management services for highly complex patients within the health center. Utilizing a high-risk patient registry and Primary Care Provider (PCP) input, the Complex Care Manager will identify the patients, perform risk stratification and conduct comprehensive assessments. The CCM will then work with the care team, and also independently, to develop a comprehensive, proactive, evidenced-based integrated care plan (ICP). The CCM will be responsible for managing an active case load, as well as maintaining a registry of complex patients. The Complex Care Manager is responsible for working with patients to identify strengths and barriers and develop an individualized, patient-centered plan of care.
What you'll bring
- Current Massachusetts license as a Registered Nurse required.
- CPR Certificate required.
- General computer knowledge: Microsoft Outlook, Office, Excel.
- Use of Electronic Medical Record required
- 1-3 years of experience working as a Registered Nurse in an ambulatory care setting required.
- Care management, or similar experience with special populations
- Bachelor’s degree in Nursing required.Master’s degree strongly preferred.
- 1-3 years of experience working with people affected by HIV preferred.