Primary Care Team Nurse Care Manager

Primary Purpose of Position:

North Shore Community Health (NSCH) is an industry leader in exceptional community healthcare delivery. The Primary Care Team Nurse Care Manager (PC team RN CM) is a registered nurse whose primary responsibility is managing a panel of patients on an assigned primary care team identified for care management. Working collaboratively with the primary care team specialty NSCH care teams and community care providers the PC team RN CM coordinates the overall health care utilization for NSCHs most vulnerable patients.

The Organization

North Shore Community Health (NSCH) is a highly accomplished community health organization that prides itself on its compassionate approach to serving the surrounding communities with comprehensive and culturally sensitive care. With a strong commitment to excellence NSCH provides:

• Comprehensive primary care.
• Dental services.
• Behavioral health care.
• Care management.
• Pharmacy services.
• Substance abuse disorder treatment.
• Nurse care management.
• Insurance enrollment assistance.

NSCH operates service sites at Gloucester Peabody and Salem Family Health Centers ensuring convenient access to care. Additionally NSCH extends its reach through school-based health centers within the Salem and Peabody School Districts. NSCH collaborates with Bentley Academy Collins Middle School Horace Mann School Bates Elementary School and the Peabody Learning Academy for behavioral health services.

As a community-based safety net healthcare provider NSCH actively encourages diversity and welcomes staff members who reflect the rich tapestry of our communities. We highly value the contributions of our team members and offer a wide range of perks and comprehensive benefits. These include health and wellness benefits tuition reimbursement loan forgiveness opportunities and other appealing benefits.

We believe in supporting our employees from day one and all eligible staff members can take advantage of these benefits right from the start of their employment at NSCH. We aim to foster a supportive and rewarding environment that empowers our team members to provide exceptional care to our communities.

Mission

North Shore Community Healths mission is to build healthy communities by providing exceptional care to all.

Vision

Healthy People Vibrant Communities

Values

Accountability

We take our responsibility to ourselves each other and the NSCH Community very seriously. We understand our individual roles and positions of power with respect to how others perceive our roles and actions. We hold ourselves accountable when we make mistakesacknowledging the error owning it taking corrective actions and moving forward. We follow through on what we commit or resolve to do.

Integrity

Integrity is the foundation of healthy relationships. We are committed to the highest ethical standards: honesty fairness respectfulness and trustworthiness. We are honorable and respectful in dealings with others and we strive to deal honestly fairly and in a respectful ethical and trustworthy manner when in agreement or disagreement.

Empathy

Empathy is a deep appreciation for anothers situation and point of view which is the basis for the golden rule and our intrinsic sense of justice. We strive to bring empathy into our interactions with each other and with our patients.

Courage

We see courage as the strength of character to stand up for our convictions and belief system. To have courage is to have the fortitude to take risks and to extend ones behaviors actions and thoughts beyond ones comfort zone. We appreciate that courage is often required to compromise. Courage is a state of mind to face adverse difficult and challenging situations with confidence and positive energy.

Respect

NSCH holds its patients in the highest regard. We provide care that is respectful of and responsive to individual patient needs and values. We take the time to listen to concerns understand what is important and provide appropriate solutions and care. We do this through coordination and integration of care collaboration and teamwork.

Commitment

NSCH is committed to the health and well-being of its community patients and staff. We demonstrate this commitment by constantly striving to align our actions with our mission vision and values.

EEO Statement:

We North Shore Community Health (NSCH) are an equal employment opportunity employer. Our goal is to have a diverse workforce representative of all people at all job levels in the organization. We do not and will not make any personnel decisions (like recruiting hiring job assignments and promotions) based on age color national origin citizenship status physical or mental disability race religion creed gender sex sexual orientation gender identity gender expression genetic information marital status status with regard to public assistance veteran status or any other characteristic protected by federal state or local law.

Essential Functions:

• Manage referrals and reports for patients identified for care management from sources such as the hospital care transitions report provider referrals and risk stratification reports.
• Outreach to engage with and manage a panel of patients as outlined in health center care management workflows and ACO guidelines.
• Assess and evaluate patient care needs.
• Analyze and interpret data and make informed judgments related to patient care.
• Document in the patients medical record and in other care management platforms according to standards set by ACO PCMH and based on other regulatory requirements.
• Create patient-centered care plans in collaboration with the patient based on individual goals preferences resources and barriers.
• Evaluate outcomes of interventions and initiate changes in care plans. Tailor care management to the patients focus helping them achieve their set goals whenever possible.
• Collaborate and communicate with the team primary care providers and other care team members to ensure quality and continuity of patient care on the primary care team.
• Connect primary care team patients with needed behavioral health services flexible services Community Partners respite care and other services.
• Communicate with the patients care team members outside the health center including specialists or visiting nurses as needed to coordinate care.
• Serve as a liaison between NSCH and other care management programs and community-based organizations.
• In collaboration with CHWs ensure patients have access to local community resources and help link care teams/patients to the appropriate resources.
• Guide the care team in accessing durable medical equipment health services and other community-based social services for patients receiving care management.
• Provide care coordination facilitate care transitions support the completion of referrals and/or provide and confirm appropriate follow-up with care providers within NSCH and with collaborating community care providers.
• Oversee hospital and emergency department discharge workflows for patients on assigned panels.
• Outreach to hospitals when RNCM patients have been admitted to help facilitate discharge aftercare with primary care.
• Collaborate with specialty nursing care teams to connect patients with services such as Hep C/HIV care substance use disorder treatment chronic disease/diabetes care and anticoagulation management.
• Participate in and coordinate team huddles or other care team meetings.
• Manage clinically related phone calls for the team including but not limited to triage of same-day appointments abnormal lab results medication questions and hospital discharges.
• Review refill requests from pharmacy and patients based on the medication refill protocol; Reconcile patient medication lists and attach pertinent information necessary for the provider to authorize the refill.
• Complete patient forms to the furthest extent possible including prior authorization forms requests for VNA services etc.
• Perform nurse visits independently and within the registered nurse scope of practice outlined by the Massachusetts Board of Nursing.
• Delegates activities to a non-nurse (i.e. medical assistant) within the parameters outlined by the Massachusetts Board of Nursing to productivity goals around areas such as/not limited to panel size patient engagement and nurse visits.
• Maintain accurate timely documentation of all nursing care and patient communication including phone notes nursing visit notes and documentation of immunizations or medication administration per NSCH policies and protocols.
• Complete documentation within the care management platform(s) as directed by the manager and as required by care management programs.
• Ensure patient quality and coding gaps are addressed and collaborate with the team to help meet population health/quality goals.
• Manage the patient panel by ensuring engaged patients receive regular timely outreach tailored to their individual needs. Graduate patients from care management who have met care management goals or who no longer benefit from care management.
• Assist with documentation/memorialization of NSCH care management program workflows and resource guides to support current and future care management team members.
• Performs additional duties to fulfill NSCHs mission as assigned.
• Hybrid position with flexibility to work remotely based on the needs of the organization.

Requirements

• College degree from an accredited nursing school with a current license to practice as an RN in the Commonwealth of Massachusetts.
• Current CPR certification.
• Experience working as an RN in a community health center or related setting is strongly preferred.
• Ability to function effectively both as a leader and a member of a team as well as a proven ability to work independently.
• Ability to work in a culturally diverse environment.
• Excellent communication and interpersonal skills.
• Excellent problem-solving skills.
• Maintains a high level of customer service with both patients and coworkers.
• Possesses strong critical thinking skills and can prioritize and address many competing demands.
• Must recognize and respond quickly to patient and/or unit condition changes.
• Spanish/Portuguese language skills are a plus.
• Experience with electronic health records and strong computer skills required. Epic experience is a plus.
• Sensitivity/skill in working with patients with complex medical psychosocial and socioeconomic circumstances such as patients with significant mental illness homelessness poverty and substance use disorders.
• The position will be hybrid (remote/on-site) based at Gloucester Family Health Center. Ability to travel to other NSCH sites for meetings and periodic clinical coverage is required. The home site may change based on the health centers needs.

As a health center NSCH ensures that all employees comply with the annual requirements for vaccinations and health screenings. All employees must be vaccinated against COVID-19 as a condition of their employment unless they have been granted a religious or medical exception. Proof of COVID-19 vaccination must be provided and prospective employees must be vaccinated before their first day of employment submitting their vaccination record and prehire paperwork. If you need to request an exemption from the vaccine requirement or have any inquiries regarding this policy please get in touch with the Human Resources Department at

At North Shore Community Health our commitment lies in fostering a diverse workforce. If youre enthusiastic about this position but feel that your previous experience aligns differently with every requirement in the job description we still encourage you to apply! Your skills could be a great fit for this role or other opportunities within North Shore Community Health.

Living on the North Shore

With facilities in Salem Peabody and Gloucester NSCH offers access to New Englands Coastal charm just thirty minutes outside Boston. The North Shore is connected to the city via the Rockport Commuter Rail line which makes stops in Salem and Gloucester. The North Shore has plenty to offer with a rich history and thriving cultural scene.

For Information Please Contact:

Talent Acquisition Department

North Shore Community Health

Salary Description

69500.00 - $107700.00

Required Experience:

Manager