Care Manager - Adult General Internal Medicine - Boston

Care Manager - Adult General Internal Medicine - Boston

Job Profile Summary 

​This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders.  In addition, this role focuses on performing the following Clinical Nurse duties: Assesses, plans, implements, and evaluates the care needs of a designated group of patients or provides nursing care and identified clinical support tasks within the scope of practice for achievement of the patient’s plan of care as directed.  Provides professional nursing care to patients. Requires a nursing license.   A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs.  The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education.   A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience.  Typically responsible for: managing projects / processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, resolving difficult and sometimes complex problems. 

Job Overview 

The Nurse Care Manager, utilizing the case management process, will work closely with the child/family, the primary Care physician, and all members of the health care team to ensure that a specific population of patients receives comprehensive and coordinated through the continuum. The Care Manager conducts comprehensive clinical assessment, develops a patient/family centered care plan including goals of care with the entire complex care team. The Care manager engages the patient and family through coaching with the focus of preparing for optimum health outcomes while preventing admissions, readmissions and adverse events. The Care Manager assesses, plans, implements, coordinates and evaluates the plan of care in partnership with the family and other members of the health care team.   

Job Description 

Minimum Qualifications: 

1. Registered Nurse (RN) license 

2. Three (3) years of experience in care management, ambulatory nursing, community nursing, home care, acute, or subacute setting. 

3. Basic Life Support (BLS) required.

Preferred Qualifications: 

1. Bachelor of Science in Nursing (BSN)

2. Specialty nursing certifications 

3. Certified Case Manager (CCM) 

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list.  Other duties and responsibilities may be assigned. 

1. Prepares for patient interaction by gathering information from reviewing the patient's medical record when available and communicating with the PCP and other members of the health care team. Completes assessments upon enrollment, transition in care and changes in health status.  

2. Coordinates all aspects of care for patients through continuum. 

3. Assesses the child/family to obtain information to identify and to prioritize, in partnership with the families, the child’s health conditions and establish goals that are patient specific. This includes self -management goals. 

4. Communicates abnormal findings and concerns in a timely manner to the provider/other members of the care team. Complete a clinical summary to provider. 

5. Conducts medication reconciliation with every transition of care and provides education and consultation with Pharmacist. 

6. Develops a care plan with the patient, family; providing all information to the PCP and the health care team. 

7. Conducts home assessments to address health care needs especially home safety needs. 

8. Documents the assessments, interactions and the care plans within the EMR. Adheres to documentation standards. 

9. Utilizes identified teachi